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° -� CITY UF PRIOR LAKE PLUMBING PERMIT
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'. B '"` F11 PERMIT NO. W �) ,�,�
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3. Yellmv Applicaat �
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LEGAL DESCRIPTION (office use only}
LOT BLOCK ADDTTION PID
OWNER \�, �� Cl,� �� ^ I
(Name �J� (Phone) `�1� a33 � I �
�Aa.a�ss� c�'7 �Cirl o l � � 12
� PLIj L � C (Phone) / � ��.� y y� �
ame
(Address) I � w ' � � Ss��j
(Address) (City) (Zip Code)
(Contact Person) {Phone} � � � �.� 7 � �'J t- '�
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELUW
Quanti T e of Fi�cture uanti e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink S#and Pi e ashin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assennbl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE 5CHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residentiai, New One & T�vaFamily $149.50
ResidentiaE, Additions & Alterations $49.50
The Minnesota Statutes § 326B.14R ��st $ Building P$rmiY #
"SLIItCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ �`'! .�"b
.T►,ty i.'1Q10, untii.fiune30, 201➢ STATE SURCHARGE $ �J•Ul7 �SQ
7'he minimum surcharge for a"Gxed fee" perrt►ir TOTAL PERMIT FEE $ �y. ._�'j
is �, beginning July l, 2QlQ
Thls Ap cation Becomes Your Building Permit When Approved Paid� �� Recei No. -
I � � — 'l � Date �
_ � �.� - �- l�- B y
B�;�amg orn�t nere
24 hour notice for all inspections (952) 44'1-9850, faa (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mlnnesota 55372