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O 4 pRip� Date Rec'd
�, CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B '"` F "` PERMIT NO.
2. �� �,Ty /� — d d� 7 �
3. Yellow Applicant
ea� ar t and si at bottom
ADDRESS �. ZONINTG cot�ce,��
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LEGAL DESCRIPTION (office use only>
LOT BLOCK ADDITION PID
owrtE� ._
(Name) (Phone) ` ' -
(Address)
APPLICANT
(Name) (Phone)
(Address) � � C � �
(Address (City) (Zip Code)
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(Conta.ct Person (Phone)
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APPLICANT SIGNA DATE
APPLICANT PLEASE COMPLETE BELOW
uanH T e of Fixture uanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Sta.nd 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
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family 5149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Pe it #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended 'LUMBING PERMIT FEE $
until rune 30, 2013, >TATE SURCHARGE $ .�s�
The minimum surcharge for a COTAL PERMIT FEE $
"fixed fee" permit is $5.00 r
rnia rippm:Aw..,. v�......��� �.,..= y......mg Permit When Approved Paid �, /' � Receipt Na � 7 ��, /
{�. f.�F
D&�2 / By •
Building Official Date
24 6our notice for �11 inapections (952) 447-9850, faz (952) 447-4245
4b46 Dskota Street S.E., Prior Lake, Minnesotn 55372
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