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� � CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File ����� �7�
2. Gold City 1\ �� ,�, �� (��
3. Yellow Applicant ��
lease or 'nt and si at bottom
ADDRES � � ! t ZONING (ofl use)
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LEGAL DESCRIPTION (oi�'ice use only)
LOT BLOCK ADDITION PID
OWNER ' Q
(Name) � � (Phone) � ` ��� � U ���
(Address) � C��VY4�
�IR
APPLICANT ��`, (�QO$Q8
(Name) (Phone)
(Address) �670 �c�d Road
(Address) ��� MN 55123 (City) (Zip Code)
(Contact Person) � 1�a. � ,.� (Phone)
APPLICANT SIGNATURE DATE � - �^ � �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fizture
Bath Tub with or without shower
Dishwasher Water Heater
Floor Drain Water So ener
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
FEESCHEDULE
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 $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid �� /�--/► Receipt Np. 7 � /
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Date � � / �— By " �—
Buildin¢ Ofticial Date
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 —^
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