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a„ CITY OF PRIOR LAKE PLUMBING PERMIT
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�. B�Ue File pERMIT NO
2. Gotd City •/ L 1/3L
3. Yellow Applicant � �
lease or ' t aad s' at bottom
ADDRESS ZONING (ot�«,�>
r� �v �O � 1�l�ce.���c� � a-r ( /V �
LEGAL DESCRIFTION (office use onty)
LOT BLOCK ADDITION pID
(NVV�NER � V V U� TU (Phone) / _J �_Z 3 �+ �7
(Address) (,(�( ' � l!W(/�Q�� � � 4 cJ� � /p�
(NameCANT ( j � (Phone) � J�� �
(Address) �� � ��Lf - `� �5 2�
(Address) ' ity) (Zip Code)
(Conta.ct Person) �� � � (Phone) 4O'� � k'�� 1 �
APPLICANT SIGNATURE DATE � ' �'V � � �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
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 artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial8c Multi-family 1% of job cost with a$49.50 minimum Residentiai, New One & Two-Family $149.50
Residenrial, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 �st $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ ��
The minimum surcharge for a STATE SURCHARGE $ G.8�0
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ S�_�
This Application Becomes Your Building Permit When Approved Paid �,/ �y) Receipt No. ��L/ �
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BulldineOfticiai Da� Date ry/�/�� By �/,..(-�
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24 6our nobke for all inspections (952) 447-9850, fax (952) 447-4245 r ,__
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 �� ��l�
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