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� �9 CITY OF PRIOR LAKE PLUMBING PERMIT
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l. Blue File pERMIT NO .
2. Gold City �� �
3. Yellow Applicant
Please or 'nt and si at bottom
ADDRESS ZONING (ot�eice use)
� l �� S �+�
LEGAL DESCR�TION (oflC'ice use only)
LOT BLOCK ADDITION PID
o�R �?- y� �
(Name) ��,�����i� (Phone) �.� ?`,,L��_
(Address) � ` � /
APPLICANT
(Name) (Phone)
(aaaress) 1313 Darlata C�
t�1ee� MN 55379 �yN^� (cit (Zip Code)
(Contact Person) 952"445'`�8A3 (Phone)
APPLICANT SIGNAT � DATE �v �I �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti 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 Washin Machine
Laund 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
FEESCHEDULE
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 § 326Bo148
" SURCHARGE " has been extended PLUMBING PERMIT FEE $ �
until ]une 30, 2013, STATE SURCHARGE $ �56
The minimum surcharge for a TOTAL PERMIT FEE .�
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid�i I J � Rec t No. /_��
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Datef, ��, � Z
Buildin¢ 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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