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CITY OF PRIOR LAKE PLUMBING PERMIT
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�� I. Blue File PERMIT NO . �`'
2. Gold City � / 7 �/� W-
3. Yeilow Ar�licant � t�� � YJ
ease or ' t and si at bottom
ADDRESS ZONING �o�� ,��
l C��S � 1 i�nc� 1��,�-ae, ���;; j
LEGAL DESCRIPTION (oflf'ice use onty)
LOT BLOCK ADDITION PID
(Na�m E rv� V� � 2�5 (Phone) 1�J �`1 `� ('` 75��
(Address) ` �� � �
APPLIC
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(Name) -- �GIiY�� l �� ��{M�p t � (Phone) .�� "��� S�� �
(Address) �� l� � 1`�1 � �c.�'Z �'� I�l �� � 2 �
(Address) (City) �:. - (Zip Code)
(Conta.ct Person) ( � (Phone) 4a �C ��7 � 3� �
APPLICANT SIGNATURE DATE �'�� � � �'
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, Commercial & Multi-family i% 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 � Building Permit #
"SURCHARGE" has been extended
until june 30, 2013, PLIJMBING PERMIT FEE $ �C( •'
The minimum surcharge for a STATE SURCHARGE $ 50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ � .- �'Z
This Application Becomes Your Building Permit When Approved Paid �– �/� Receipt No
`y" z � /
Date /�/ /� By /—
Building Offfcial Date 7 .�>-�•��
24 6our notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakote Street S.E., Prior Lake, Minnesota 55372 Li��
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