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� CITY OF PRIOR LAKE PLUMBING PERMIT �,�� ��
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��°�� ,. B�ve File pERMIT NO. n
2. Gold City � / �. �
3. Yellow Applicant ���
t d bo
ADDRESS ,_ ZONING �ot�ce,��
�s3�3 /1.��1 /�'l� S'�',
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
ame O {Phone} Z37, d �/�
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Addxess) (City) (Zip Code)
(Contact Person (Phone)
APPLICANT SIGNATURE DATE / �/ �
PPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower 5tall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercia( & Multi-family 1% of job cost with a$49.50 minimum Residenrial, New One 8c Two-Family 5149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 t$ Building Petmit #
"SURCHARGE" has been extended
until june 30, 2013, PLUMBING PERMIT FEE $ '�� �
The minimum surcharge for a STATE SURCHARGE $�-d�
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ ,�
This Application Becomes Your Building Permit When Approved Paid 3-� � Rece' t No.�� ���
Date� ,_ /� . / L BY
Bniidin¢ OYt[c1a1 Date •
24 6our noUce for all inspections (952) 447-9850, faa (952) 44T-0245
4646 Dakota Street S.E., Prior L�ke, Minnesota 55372
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