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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2. cola city ` PERMIT NO . / / /3/0
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) l t Il..!/t ( a a 40 (f f1 (Phone) 95L- 1 44-(7- (77 5 .) Z
(Address) �` ICJ
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(Name) a /RA A l 0 a (Phone) k5 I ()4 < qo
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(Address) _ 0 b AP. �. ► Al
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(Address) (City) � (Zip Code)
(Contact Person) 0 (Phone) (6S1 �6 (?M 0
APPLICANT SIGNATURE / / .. DATE ) I — �O ---
4
A ' ' LICANT PLEAS CO MPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 Cost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ Ai
The minimum surcharge for a STATE SURCHARGE $ Iligt 0
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ '�
This Application Becomes Your Building Permit When Approved Paid 5, ' • - ipt No. 64.1 ? ( .
Date 1Z i (2,11 )J
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 g I d (-,� �
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 J v �n
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