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CITY OF PRIOR LAKE PLUMBING PERMIT
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4JNNESo�P Blue File
2. Gold City PERMIT NO. 0 .�2b
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (o
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5SS SS\ c � �� ` 1\1 ^ rrice use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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# 61770 -PM
APPLICANT 651- 365 -1340
(Name) 3670 Dodd ld. (Phone)
Eagan, MN 55123
(Address)
(Address) (City) (Zip Code)
(Contact Person) K\rt, ` f � ' (Phone)
APPLICANT SIGNATURE //� / �� DATE
1a--1(.0—, I
di APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Ro . 1 .
Dishwasher
Floor Drain , "" a er o tener
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 $ e °"1' 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 $ O
This Application Becomes Your Building Permit When Approved Paid S ,, e eipt 17
Buildine Official Date Date
1 . (c • (Z / ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ( ()A? °)