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,° � CITY OF PRIOR LAKE PLUMBING PERMIT
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�. g��e File pERMIT NO.
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3. Yeliow Applicant --
ease or ' t and si at bottom
ADDRESS ZONING (oR'ice use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION pID
OWNER � /�� �
(IVame) (Phone) – �i�- (•� �
(Address)
APPLICANT
(Name) (Phone)
(Address) ���� � ��
( �� _ (City) (Zip Code)
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(Contact Person) (Phone) _
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APPLICANT SIGNA � DATE I
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanH T e of Fiature
Bath Tub with ar without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Sta11 Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercia( & Multi-family 1% of job cost with a$49.50 minimum Residential, New One 8c Two-Family $149.50 ,
Residential, Additions & Atterations $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended PLIJMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $
The minimum surcharge for a TOTAL PERMIT FEE $� r� ��
"fixed fee" permit is $5.00 � �� -
= u.a .� y.:..v...�a �..... L..,�..ing Permit When Approved Paid��/ � Receipt No. , �
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Date f �� , By �
Buildin¢ Ofticiai Date
24 6our notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mianesota 55372
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