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� � CITY OF PRIOR LAKE PLUMBING PERMIT
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�INNESD�P I. Blue File pERMIT NO .
2. Gotd ciry �� � ���
3. Yellow Applican[
lease or 'nt and si at bottom
ADDRESS ZONING (oflEice use)
� �J J �C��l �20� �'� 1(� � �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1_ P CAT /�
(Name) ��� i" l 1V A l� [ _ ' �:i (Phone) � I Z �� � � — V � �
(Address) ? j 3r� hf, � � �le., t /� "�
(NameC���� � ���i "/'�� � �' � �D (Phone) !��" � �G� ` �� ��
(Address) � � �� � - / ` / � � � � � �
(Address) (City) (Zip Code)
(Contact Person) � 1 J� !w� (Pho e) �� r ����0 (J / �
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APPLICANT SIGNATURE GC!DATE 1
A PLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture Quanti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water 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
FEE SCHEDULE
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
The Minnesota Statutes § 326B.148 �ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ .�Q
The minimum surcharge for a STATE SURCHARGE $ .
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid ��/ 1 �, Receipt No. � p�}�
�)F J (J 7 7
Date�/� � By
Buildine Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372