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� �RIp Date Rec'd
���" ����`� � CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue Pile pERMIT NO .
2. Gold Ciiy / I ` � �
. 3. Yellmv Applicanl
ease or t aad si at bottom
�D�SS 3 2-I ��.. ��,v�e. ��l Zo�G�o�ce�,
LEGAL DESCRIPI�ON (oAE'ice nse only)
LOT BLOCK ADDITION PID
OWNER �,(� �Q �I � � !, �� l �
(Name) (Phone)
(Address) I � �� ! v ""
� PLIj ANT 1 C�.i� e•� w �' {phone �v �i �t `�i'`� "`��
ame )
(Address) J � �_ ��� � � ��F'���
Address) „ {City) (Zip Code)
(Contact Person) (Phone) _
APPLICANT SIGNATURE DATE `
APPLICANT PLEASE COMPLETE BELOW
Qnanti T e of Fixture uantl of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e ashin Machine
Laund Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Back£�ow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
Industrial, Commercial & Multi-family 1% of job cosi wiih a$49.50 minunum Residential, New One & Two-Family $149.5U
� Residentia(, Additions & Alterations $49,50
The Minnesota Statutes � 32U.B.148 � �st $ !/V� ' $uilding Pertnit #
"SUitC..HARG�" has been changed For one
year effective PLUMBING PERMIT FEE $
.1e,1s� a, zOYO. �,nc91.➢une 30, ao� i. STATE SURCHAR.GE $ 0
7'he minimum surcharge for a "Eiaed tee" permit TOTAL PERMIT FEE $
is ^��i, begFnr�ing 3uly 1, 301Q �
This Applic�tion Becomes Your Bailding Permit When Approved Paid�� � Rece' 0.�3 �iS
Date �` � /
Buildlns Offidal Date [
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372