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CITY OF PRIOR LAKE PLUMBING PERMIT
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��$�� ,. B `�` F ''` PERMIT NO.
Z. �,� ��� �- l L-/�79
7. Yellow Appiicant
t882 O! � t SIId St �/0[[Onl � '
ADDRESS � ZONIlVG (oe�ce,��
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N�� ��e ��t �� � (Phone����i'� ����
(Address) -
APPLICANT
(Name) r� ��ti011S 111C. (phone)
(Address) Sh11k M1�155379 �V � P �.�'
(Address) (City) (Zi Code)
(Conta.ct Person) � (Phone) _
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APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fi�ture uanti T e of Fizture
Bath Tub with ar without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroorn 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 I% of job cost with a$49.50 minimum Residentiat, New One & Two-Family S 149.50
Residential, Additions & Alterations $49.50
_s
Estimated Cost $ _ Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended PLUMBING PERMIT FEE $
until june 30 2013 STATE SURCHARGE $ �
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
�..,a n D�vmes Y our �suilding Permit When Approved Paid 1�/� Receipt No. ry ��
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Date 1 ., /� /L By
Baildin¢ Oft[ciat Date L�
Z4 hour notice for all inspections (952) 447-9850, tax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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