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CITY OF PRIOR LAKE PLUMBING PERMIT / Z / INNESc
1. Blue File 1 2 8
z Gold City PERMIT NO. L
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / / � / ZONING (office use)
/7r /
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O R ) �O� �V : i2 kiA
(Na /,,,,i P ne
(A ress)
APPLICANT
(Name) 0 4 / ' • / (Phone)
a ' i s
(Address) /mil a.. i' Ai .6/ 411/.4
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE Jr ai,�.7 %/ i�C:u� DATE 0 02 —01-- ®/
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher X 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
ost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE” has been extended PLUMBING PERMIT FEE $ i . 573
until June 30, 2013, STATE SURCHARGE $ S 0Orj
The minimum surcharge for a TOTAL PERMIT FEE $ `j I .O
"fixed fee" permit is $5.00
This Apph/ io l ecome i .. '.. ' • I I 't he A pproved Paid 5� j - 5
Receipt No. 0 1
A It 7. 7 i Date By 1
t uil?l!! ! l ff i`i al ate Z 2 4 Z.
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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