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� �� CITY OF PRIOR LAKE PLUMBING PERMIT il �,�—�
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1. Blue File ����r�. �7�
2. Gold City 1 1\ /� . Z�'
3. Yellow Applicant � `•�
Please or 'nt and si at bottom
ADDRESS ZONING (o�t'ice use)
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�02 7 � ri S � �'l �c � !_�
LEGAL DESCRIPTION (oflE'ice use onty)
LOT BLOCK ADDITION PID �
OWNER
(Name) (Phone)
(Address)
APPLICANT
(Name) "�� L' l� �� +t2 �O �I � � � f (Phone) � / � � S<SO ^ /�' `f l
(Address) � `f' 7 � d ��` � `� � � v �C � /' '' f DYJI�( (/���'"�� � � s�s�� t "T
(Address) (City) (Zip Code)
(Contact Person) � c,c � �PI/�� t'� (Phone) �Q/ Z — �{ � d ^ l ��/�
APPLICANT SIGNATURE lt ��`'� `"' < <G'�'� DATE � ` �� '- l Z
APPLICANT PLEASE COMPLETE BELOW
Quanti 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 Washin Machine
Laun Tra 1 or 2 com arhnent 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-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 ='ost $ Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ .5 V
until June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ , v�
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This Application Becomes Your Building Permit When Approved Paid �, L� Rec No. /„�
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Date B
Buildine Ofticial Date � • � � �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372