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�� CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File pERMIT NO .
2. Gold City � �
3. Yellow Applicant
lease or 'nt and si n at bottom
ADDRESS •.., �, ZONING (ott'ice use)
I� i C�U �.r� r�S� i� �S�c�Y�1c� � a�c�
LEGAL DESCRIPTION (of�'ice use only)
LOT BLOCK ADDITION PID
(Na ) R C S� (Phone) � I� 1�"1 1��J 1 C�
(Address) ` � �,S I � � � � ��
APPLICANT G C" � �/ _�_ //�/� �
(Name) Z� (Phone) � J �.Q I V� J
(Address) � � � S �'� e- �
(Address) (City) (Zip Code)
(Contact Person) �l/�-� u- � \�� � (Phone) � J� � ��
APPLICANT SIGNATURE � DATE � 2
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti 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 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-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 $� 1°� Building Permit #
"SURCHARGE" Y►as been extended pLUMBING PERMIT FEE $- I�•�
until June 30, 2013, STATE SURCHARGE $ • W
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
__ _ .
This Application Becomes Your Building Permit When Approved Paid� � Rec p o. � r�w�Z,c
�U.�U
Date� �� � � B
Buildine Ofticial Date
24 hour notice for all inspecrions (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372