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�, CITY OF PRIOR LAKE PLUMBING PERMIT
N �
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��S ,. B�ue File PERMIT NO.
2. Gold City �� � � /� � /
3. Ye11ow A�rlicant V
lease or ' t and si at bottom
ADDRESS ZONING �ot�ce �}
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LEGAL DESCRIPTION (ot£ice use oniy)
LOT BLOCK ADDITION PID
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(NW�NEB Q'Y� �' �u'`C� � l � � (Phone) f ����� � I ` e'
(Address) � � � �� � ' �j Z
APPLICANT - /' f ( �,/
(Name) O (Phone) (.�� l � 19� L ���
(Address) +" Y I � � �
(Address) ity) (Zip Code)
Contact Person �
( ) �. � (Phone) �� �� .J�r 0
APPLICANT SIGNATURE � DATE �� Z-� l�
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanti T e of Fizture
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 Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commerciat & Multi-family 1% of job cost with a$49.50 minimurn Residenrial, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 `$ Building Permit #
"SURCHARGE" has been extended
untii ]une 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 � rn Receipt No. ` iy� �
J� GY
Date � r --/� L By
Baildin¢ Official Date .7 /
24 6our notice for �ll inspections (952) 447-9850, fax (952) 447-d245 �
4646 Dakota Street S.E., Prior Lake, Miunesota 55372
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