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O � pRip� Date Rec'd
,� CITY OF PRIOR LAKE PLUMBING PERMIT
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�. B�� File pERMIT NO. /��
2. Goid City I����y
3. Yell�w Ap�licant / �
leaae or ' t and ' at bottom
A����� � � ZONING (ofle�ce use)
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LEGAL DESCRIPTION (office use onty)
LOT BLOCK ADDITION PID
OWNER / ,
(Name) (Phone)��' ��'` ���
(Address) ( � b'� �
APPLICANT
(Name) �p.pliance Cot111@CtiOf13 ��. (Phone)
"?R50 Chestnut Btvd.
(Address) T��*e°�,"�"N ra�a37�
(Address� (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNA DATE � �r
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
Lavata athroom 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, Commercial8c Multi-family i% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
$ Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended PLUMBING PERMIT FEE $ P�
unril june 30, 2013, STATE SURCHARGE $ , 7,a(� :59-
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 f
This Application Becomes Your Building Permit When Approved Paid� �� Receipt Na 6 a 7 � —
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Date P / � By /
Buildia¢ Official Date `��� �.
24 6our notice for all inspections (952) 447-9850, fax (952) 447-4245
A646 Dakota Street S.E., Prior Lake, Mianesota 55372
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