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� � pR Date Rec'd
�� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B`°e F'`e pERMIT NO. � �"
z. coia ciry /�'
� 3. Yellow Applicant
lease e or ' t and si at bottom
ADDRESS ZONING (otice use)
I �I Ca� �n
LEGAL DESCRIPTION (ot3Fice use only)
LOT BLOCK ADDITION PID
� ��\ � �� I������ a (Phone) - 1 . '" 1
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(Address) m �
APPLICAN �`����� 2 ( p . �1
(Name) 1 (Phone) t�"j1�
(Address) � �
(Address) ity) (Zip Code)
(Contact Person) (Phone) 1 � , (� �
APPLICANT SIGNATURE DATE I ��� — � �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fizture
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 arirnent sink Sewa e E'ector
Shower Sta.11 Backflow Assembl
Sinks Backflow Assembl Test
Bax 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
- - _ Bstimat�d Cost $ Building Permit #
The Minnesota Statutes § 326B.148 U(y ,�
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ �"�
until June 30, 2013, STATE SURCHARGE $ 'S6
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
�1 nis appucanon �secomes z vur nuilding Permit When Approved Paid �/ 1� Receipt No. � j /D �
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Date j � J � By •
Buildine Official Date E �
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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