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� � CITY OF PRIOR LAKE PLUMBING PERMIT � Z � � Z
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,. B�°e F;�` PERMIT NO. j�, .�� 1�
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3. Yellow Applicant
ease or ' t and si at bottom
ADDRESS / •¢ 'D �.� �(rv���� �� �(/(�� ZONING co�� �)
LEGAL DESCR�TION (office use only)
LOT BLOCK ADDITION � PID
(N� ) r v C' `� (Phone) ��Z ' Z� 3�3s7�
(Address) 1 a r�' l t1e � ^ t'at , 14J Y
��e)ANT e (aw���:, L,C e-4�) / .�1�2�� -q3/d
(P one) �!7
(Address) Z � (T rP� A. � �� et �✓P . � O �o fft c Gro% 5�O/�
(Address) (City) (Zip Code)
(Contact Person) e �� (Phone) �bs ) 2-? ` "� � 3 � �
APPLICANT SIGNATURE DATE � 2
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Figture uanti T e of Fiatture
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 Claset 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
� � �t $ Building Permit #
The Minnesota Statutes § 326B.148 �
" SURCHARGE " has been extended pLUMBING PERMIT FEE $ � Sv
until june 30, 2013, STATE SURCHARGE $ ✓�� U7�-59�
The minimum surcharge for a TOTAL PERMIT FEE $_,�
"fixed fee" permit is $5.00 ----
T6is Application Becomes Your Building Permit When Approved Paid��-- `� Rec i No.� ���
Buudins Official Date Date� �/• `L B
�
24 hour notice for sll inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372