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O ,� pR[p� Date Rec'd
�, CITY OF PRIOR LAKE PLUMBING PERMIT
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�`�$°�� ,. B�Ue File PERMIT NO
2. Gotd ��� . � q y
3. Yeilow A��licant
lease or ' t and s' at bottom
.ADDRESS ZONING �ot�ce ��
� � l�j�'1 �1'� �t.. �i�u:r J �j�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � ^ � �O Ia� � � � �
(Name) �, J`� LQ � � � �Z (Phone) �O�'
(Address) ` LC(,,� m ' � �� �
APPLICANT . .
(Name) ►�l (Phone) ����,� — �� �
(Address) � � • � I V. �� � J
(Address) City) (Zip Code)
(Conta.ct Person) � � � (Phone) (c� � � � � � J ' � �`� �
APPLICANT SIGNATURE DATE � �� � �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e ashin 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 l% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Addirions & Alterations $49.50
The Minnesota Statutes § 326B.148 �t $ Building Permit #
"SURCHARGE" has been extended
until June 30 2013, PLUMBING PERMIT FEE $ •�J�
The minimum surcharge for a STATE SURCHARGE $
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ cj(..-� ,�,�
This Application Becomes Your Building Permit When Approved Paid \,�--�� Receipt No. ` � i ��
E� r
Date By ,.�
Buitdins Official Date (� y'
24 6our notice for all inspections (9S2) 447-9850, fax (952) 447-4245 (,� ,,�
4646 Dakota Street S.E., Prior Lake, Minnesota ss3n ��?��
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