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CITY OF PRIOR LAKE PLUMBING PERMIT
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��°�� ,. B�ue File PERMIT NO.
2. Gold City � f L� j D/�
3. Yellow Applicart
CBSt Oi BYtd S� 8t bO�LODl
ADDRESS ZOIVING comce �)
a 1 �l -
LEGAL DESCRIPTION (office use oniy)
LOT BLOCK ADDITION PID
OWNEK
(Name) (Phone) �� � �/,1��-
(Address) �! � �
APPLICANT pp Ia11C@ �nnec �ons 11C
(Name) �T,� 11���� (Phone)
(Address) Shakopee, MN 55379
(Address ,_ 952-445-4803 (City) (Zip Code)
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(Contact Perso 1 ° tr (Phone)
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APPLICANT SIGNATURE �J DATE
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Figture uanti T e of Fixture
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
Industriat, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residenrial, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 t$ Buitding Permit #
"SiJRCHARGE" has been extended pLUMBING PERMIT FEE $ ��
until june 30 2613 STATE SURCHARGE $ .04�-.59'�
The minimum surcharge for a
, "fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Yonr Buildieg Permit When Approved Paid � b/`� Receipt No. 4 � D
7
Date � i / �� By �
Buitdias Ot[icial Date
7`
24 6anr noNce for �Il inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E, Prior Lake, Minnesota 55372
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