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� � CITY OF PRIOR LAKE PLUMBING PERMIT ��� ��
� '�
�INNES��� 1. Blue Fi1e
2. Gold �;� PERMIT NO. /�,�/
3. Yellow Applicant
lease or ' t and si at bottom
ADDRESS ZONING (ot�'ice use)
(`� ( �� �2�..c,��s� �— a��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � = hone) �� G �������
(Name) (P
(Address)
(Name) A �3`�� L �f V �cn9�Q�'"L,� (Phone) �0�, �0�.5 `�o2.,.Z
(Address) 7��i� �'2 Q-� �t ��°r�-�. � ��� � �
(Address) (City) (Zip Code)
(Contact Person) � � (Phone) �O � � �� � °
APPLICANT SIGNATURE DATE � �� � �
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
Laund 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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ ��
unriT June 30, 2013, STATE SURCHARGE $ �< D'Z_:�E)
The minimum surcharge for a TOTAL PERMIT FEE $ ,.S�
"fixed fee" permit is $5.00
- i Appn ro,� nII�iing Permit When Approved Paid�� � Rec No.�3� �
Date , 3 /_ � zr •
Buildine O�cial Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372