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� pRlp Date Rec'd
F �� CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File ��77�T�r�. �7�
2. Gold City lllvl 1 1\ �
3. Yellow Applicant
lease e or rint and si at bottom
ADDRESS ZONING (oft'ice use)
43s a ��,�5���.� �.a�,� 5 �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER `
(Name) ��M � O 1'� ►1 5 0�'1 _(Phone) 9� a- a3 3-�a a 0
(Address)
APPLICANT
(Name) CIJLLIC.�AN WATER (` �r�r,.��.�.. (Phone)
6030 CULLJCaAN �1UAy
(Address) M f N N ETp�K� ��,�r�.c�
r`_ (Ac�dre��5�� 933 7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 3 � y ��
APPLICANT PLEASE COMPLETE BELOW
Quanti 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 5ewa 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
The Minnesota Statutes § 326B.148 �st $ ���, vU Building Permit #
"SURCHARGE" has been extended
until �une 30, 2013, PLUMBING PERMIT FEE $ �� S�
The minimum surcharge for a STATE SURCHARGE $ ��-�
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ �4 .S�
This Application Becomes Your Building Permit When Approved Paid � ,� c ipt NaX_ �3 �
l9
Date 3 � • � -
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