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o A, alt e CITY O P 'i OR LAKE PLUMBING PERMIT 1
Q.(4 4
A
I. Blue Pile PERMIT NO.
2. cola city
3. Yellow Applicant / z i
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
77 4/:// . i4- 1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) �v/ Z°r„'4v // (Phone) C� -0s • /...2.-- (Address) //' j r' ' /�
APPLIC
(Name)," / A G ://' - � , � - h� � '.e.... (Phone) o/Z 122. - - .mil e-
(Address) 07/ 7 -�r/ / / 4V /hrz.e . - -..4.V. - -.�/
/ �
/ ( Address ) (City) (Zip Code) t
(Contact Person) s ill - e-- i /- (Phone) diZ L - .r t-
APPLICAN , SIG ATURE DA'1'1✓ ���4z ---
A'f" CANT PLEASE COMPLETE BELOW
Quantity ( ype of Fixture Quantity Type of Fixture
Bath ith or without shower Rough - ins
Dishwasher / 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 Est $ Building Permit #
"SURCHARGE" has been changed for one g r
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE ■ $ 44
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE
is 5, beginning July 1, 2010 L V ; u .. 2
• This Application Becomes Your Building Permit When Approved Paid iRecei INo.
1 .1 N 21 2012 Eli �'�
Date By
Building Official Date
C -
24 hour notice for all inspections (952) 447 : i, x'(52) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372