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� �� CITY OF PRIOR LAKE PLUMBING PERMIT S -. ��� ��
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L Blue File pE�IT NO . /�, i/�/ /(„
2. Gold City / V ��
3. Yellow Applicant
lease e or rint and si at bottom
ADDRESS d ZONING (oflEice use)
5��� Le�f� �����
LEGAL DESCR�TION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER ` ) �C�'"�" y�,�
(Name) � r 11 (Phone)
(Address)
APPLIC T� , y �f',,
(Name) � �� �� �� � � f� �LU �IYI g IAI t� LL' (,, (Phone) `� ( Z —' � � � �� � �
(Address) r � - [ �� �t/ � � �' � J1�1 C'�` � � k� 1/ ) �� S y Zl
(Address) (City) (Zip Code)
(Contact Person) A n' �� �KE � (Phone)
APPLICANT SIGNATURE DATE � l � � �--
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
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 $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ _,S(,�
.
This Application Becomes Your Building Permit When Approved Paid s,/ S � Recei o. ���
7"
Dates � � �2� By �
Buildin¢ Ofticial Date �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372