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4 VRi Date Rec'd
N CITY OF PRIOR LAKE PLUMBING PERMIT
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4 INNESO
1. Blue File
2. Gold ERMIT NO . -27 4
3. Yell Airy ow Applicant k.3
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
14 5 T1 nb M ‘
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER -
(Name) F eAe. � L o X (Phone) 9S31 -
(Address) & a S Of L. a ' V .' i \ S "J Ji a
APPLICAN `� -
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(Name) ry (( .Y � ( (Phone) \ 3 0
� ;- 1 pd . (Address) cllJ � � A�V(,� � � C1.1--1 ly1 � ( - r-s-) t a a
(Address) ( (Zip Code)
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(Contact Person) , 5 (Phone)
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APPLICANT SIGNATURE -4.0 DATE — - 1 "-' I -S
APPLICA PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I Water Heater
Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B,148
Dst $ Building Permit #
"SURCHARGE" been changed for one PLUMBING PERMIT FEE $ "l2 ` 6 0
year effective G4"
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ j .59
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is ss beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid � -- , / Receipt No. 72 —
Buildine Official Date Date (/ // By i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 2,C111
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