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CITY OF PRIOR LAKE PLUMBING PERMIT
V
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2: �a,d �;� ( PERMIT NO.
3. Yeilow Applicani � �� � � ��
lease ar' t aad s' at bottom
ADD S � ZONING (otrt'ice �se)
1�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ' '
(Name) (Phone)
(Address) (i��'1��'"�- ��� �
APPLICANT PC ��Q308
(Name) (Phone)
651-3 �
(Address) ���n n,�,�� Rp�d
(Address) ��� MN 55123 (City) (Zip Code)
�
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE L� � r �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Figture uanti T e of Fia�ture
Bath Tub with or without shower -
Dishwasher Water Heater
Floor Drain Wate er
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 5CHEDULE
Industrial, Commercial & Multi-family i% of job cost with a$49.50 minnnum Residential, New One & Two-Family $]49.50
Residential, Additions & Atterations $49.50
The Minnesota Statutes § 326B.148 �st $���_s'� Building Permit #
"SURCHARGE" has been extended
until june 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ 50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $�,�—
This Application Becomes Your Building Permit When Approved Paid�'� �/�� Receipt No: /�I /L
•T ro L� T
Date �/� 3 `� y By
Bu��ai� or�i� nac� /
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ��
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