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� CITY OF PRIOR LAKE PLUMBING PERMIT /� �` ��
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�. B��e File pERMIT NO. /�
2. Goid City
3. Yeliow Applicant � °
o and si at bottom
ADDRESS ZONING (o6fice use)
� G��.vL� l� -
LEGAL DESCRIPTION (off'ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) � � (Phone)
(Address)
(Name) T �f.Cfi� � (Phone) � � �
(Addre �Z � `
_ (Addxess) (City (Zip Code)
ontact Pers (Phone)
PLICANT SIGNA DATE ���
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fiztare uanH T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 com arirnent sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCIiEDULE
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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148 �
"SURCHARGE" has been extended LUMBING PERMIT FEE $ ,
until june 30, 2013, TATE SURCHARGE $ .5.
The minirnum surcharge for a 'OTAL PERMIT FEE $_� .
"fixed fee" permit is $5.00
rnis Appucazion a�om� � o..r D�uu.ng Permit When Approved Paid�� i � Re i t No.
B�iw�g or�� nar� Date/ �). � 3 BY
24 hour not3ce for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mtanesota 55372