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O 4 PRIp� Date Rec'd
� � CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File ����rT. �7�
2. Gold Ciry I l� `� _� �
3. Yellow Applicant ' ��
lease e or rint and si at bottom
ADDRESS ZONING (oflFice use)
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LEGAL DESCRIPTION (oflE'ice use only)
LOT BLOCK ADDITION PID
o�R ��z 7Z�
(Name) r (Phone)
(Address) � � � � �
APPLIC , °' �( ( O I
(Name) (Phone) `'1.
(Address) ✓ ( �
(Qddress) (C' ) (Zip Code)
(Contact Person) (Phone) �� � �`L�
APPLICANT SIGNATURE DATE � �� �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin 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
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
�st $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ ��
until june 30, 2013, STATE SURCHARGE $ �$"'
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 �
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Buildine Ofticial Date
24 6our notice for all inspections (952) 447-9850, faz (952) 447-4245 �/�
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 r� . I(/
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