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to CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File
2. Gold City PERMIT NO . / / zgo
3. Yellow Applicant 1 1 .
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 I1 k(,mr\i L II G + .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) CAr\ot l( I 't S ') (,l- ►` 0 I a (Phone) a�� - � 7' !$
(Address) rl•e_ b..-e --
APPLICANT
(Name) (Phone)
(Address) 31- 1815874
Ape Connections nc (City) (Zip Code)
(Contact Person) 1313 Danita Circle .
(Phone)
APPLICANT SIGNATURE _ /AIL r / � `/i �' DATE ( 111
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain I 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 ;t $5 � JZ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ P INI.
This Application Becomes Your Building Permit When Approved Paid 5 4 s z eipt No. j„,L
Date l9'T `
Building Official Date I, „k ' V
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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