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4 PRIp Date Rec'd
� �� CITY OF PRIOR LAKE PLUMBING PERMIT !� Z,/ Z
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1. Blue File pERMIT NO . / Z ` �3
2. Gold City
3. Yellow Applican[
Please or 'nt and si n at bottom
ADDRESS ZONING (ot� use)
37� T . �'G�/,
LEGAL DESCR�TION (ofi'ice use only)
LOT BLOCK ADDITION PID
OWNER n . � 3 � �7�
(Name) /�L1� � j'V( Q7(f l� (Phone) � 5 Z� �� Ll
(Address) � 1 � � ,Q /' ' �-R-K.L..
APPLICAN� � / 2' �� ry ���
(Name) 0��0 ���e�ll�C�J (Phone) �f -
(Address) 1�� Y �i �� /�i/'e / 11 � / �4/ � YV1 �1 , - ��fQ"
(Address) (City) (Zip Code)
(Contact Person) �o �LvW"l (Phone)
APPLICANT SIGNATURE �����/� Q"� DATE •/ � J � Z
APPLICANT PLEASE COMPLETE BELOW
uanN 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 ashin 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
'ost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended pLUMBING PERMIT FEE $
until june 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 �
This Application Becomes Your Building Permit When Approved Paid ��Sv Receip o. ��/ /
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Date , / �, UL By
Buildin¢ Official Date 7
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372