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� � pRro�� Date Rec'd
F 9 CITY OF PRIOR LAKE PLUMBING PERMIT ��.
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�j�'NES��� 1. Blue File pERMIT NO .
2. Gold City � '� � "'�j
3. Yellow Applicant ���
lease e or ' t and si at bottom
ADDRESS ZONING (ot� use)
� � � �a � � ^ t�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I
(Name) � � c� -^� �� t �. (Phone)
(Address) 7 � � � � �� � `V' ". �
APPLICANT� /� `,
(Name) � �.Gt, 5 ��C/ �� (Phone) (o � � `" .� jj'� ' � � 3 f
(Address) � � 'C�-�-- � � �'J Z
(Address) (Ciry) (Zip Code)
(Contact Person) �� (Phone)
APPLICANT SIGNATURE DATE � �
i
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
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
FEE SCHEDULE
Industrial, Commercial & Multi-fatnily 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
°SURCHARGE" has been extended PLUMBING PERMIT FEE $
until june 30, Z013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
� n�s r3ppucaTron �ecv��z ���ding Permit When Approved Paid/� R e' t No �� Q �
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Dat . �
Buildin¢ Officfal Date - ��
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372