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� � CITY OF PRIOR LAKE PLUMBING PERMIT
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�j�'NES��P 1. Blue File PERMIT NO . � ���
z. �oid c�ty
3. Yellow Applicant
Please e or rint and si at bottom
ADDRESS ZONING (office Use)
�O � � U�J�� �,� � I r,� � �
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
� � `� � (Phone) U/ I P "�LL� � . >
(Address) <� �- V 1� C v � � � ��
APPLICANT
(Name) � (Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) � (Phone)
APPLICANT SIGNATURE DATE �1 ~ I ��� {�
APPLICANT PLEASE COMPLETE BELOW
Quanti - T e of Fixture uanti T e of Fizture
Bath Tub with or without shower
Dishwasher ater 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
' ' "ost $ `� � Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended pLUMBING PERMIT FEE $
unril June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ 5
"fixed fee" permit is $5.00 '
_ ------- — - _
This Application Becomes Your Buffding Permit When Approved Paid � �;� Recei o.� ��/
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Date � By
Buildin¢ Ofticial Date ` �� r' �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ���