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CI OF PRIOR LAKE PLUMBING PERMIT
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4 / 1 i'NEso t. 1. Blue File
2. Gold city PERMIT NO. / / / 2 zs
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
&-/L7 Conro
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER j v� - y i • L • �
(Name) (Phone) 95� - 2 SS ) L7
/,� �. �� (Phone
(Address) �■ r i or Lake-1 rY N • CD -23- Z
APPLICANT 0 _
(Name) I I vA (Phone) Ot ` l -1 SIP
(Address) - .. fb t _ A /. , — - -i. J
• ddress) (Ci (Zip Code)
(Contact Person) _ (Phone) - 4 6E 7 I 340
APPLICANT SIGNATURE DATE _LJ "w 0
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher f 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 :ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ t 5_
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 1m O()
This Application Becomes Your Building Permit When Approved Paid SL4 S-) Receipt NI 4�
Date I I ' U j
I .
Buildine Official Date
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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