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CITY OF PRIOR LAKE PLUMBING PERMIT
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�j�'NES��P t. Blue File pERMIT NO . � M /� ^
2. Gold City �' )
3. Yellow Applicant ' � � ✓
Please or rint and si at bottom
ADDRESS ZONING (olTice use)
y I� l.rt�,��- 1\; f�oa
LEGAL DESCRIPTION (ott'ice use only)
LOT BLOCK ADDTTION PID
(Na�me)�a� � � �v.na�w�t" (Phone)
(Address) �a.�.�.�
(Name) �a�v � �c�u c�''^�1'" (Phone) - 1 �� ' L �� 0 "' � � � Z
(Address) Sa-^^�^�.-
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE J t+�+.c �� 201 Z
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher I Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e ashin 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
- "-`=--- -' ' " st $ 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 $ S�/, 5 �
"fixed fee" permit is $5.00
- __
This Application Becomes Your Building Permit When Approved Paids �� Rec i t N G�
Date� G �, By
Buildine Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Miunesota 55372