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� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B�°e F'� Y pERMIT NO. �' L� �lSy
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3. Yellow Applicant
lease or 'nt and si at bottom
AD �$$ �� i � �� t t� ZONING (ot�'ice use)
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LEGAL DESCRII'TION (office use only)
LOT BLOCK ADDITION PID
OWNER (,/
(Name) O (Phone � / �
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(Address) � ° ���
Plumbin
APPLICANT pC ppd308
(Name) (Phone)
(Address) 3.�,70 DOdd F�OSd
(Address) ��� MN 55123 (Ciry) (Zip Code)
(Contact Person) ����� � (Phone)
APPLICANT SIGNATURE DATE � ` � � �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanti T e of Fizture
Bath Tub with or without shower
Dishwasher Water Heater
Floor Drain r
Lavato Bathroom 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 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
�st Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ ��
until june 30, 2013, STATE SURCHARGE $ �, t9
The minimum surcharge for a TOTAL PERMIT FEE $��� S�
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid �, f� Receipt Nck . G
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Date 1U � 2� 2 B y
Buildin¢ Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ��
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