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CITY OF PRIOR LAKE PLUMBING PERMIT i 3 2
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Please or 'nt and si n at bottom
ADDRESS � � � ZONING (ott Use)
�1�� 5 r�r�,� �� ��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�a'WNER ��d / � /Q f` I 1 V\. �Phone) l J z �� � � �
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) � (Phone)
APPLICANT SIGNA,TURE I�ATE / �� �/ �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fixture
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 ' ler
Water Closet Toilet Other � '
.
FEESCHEDULE
Industrial, Coxnmercial & 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 L}- �
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ ! —
undl June 30, 2013, STATE SURCHARGE $ .5
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid � s � Rec No. / Z/
lY �
Date ` 3, Z By
Buildine Official Date '
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372