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O 4 PRip� Date Rec'd
� 9 CITY OF PRIOR LAKE PLUMBING PERMIT
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L Blue File ����rT, �7� � ��,
2. Gold City 1 1\ ��
3. Yellow Applicant
lease e or rint and si at bottom
ADDRESS � ZONING (oflE'ice use)
�- Lt y C� i l�C� �' � Yl� S� �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION pID
OWNER � �J
(Name) �. � i , (Phone) �� � � C--CU y� y3
(Address) �� � � ' C- ��� l �,�'' / � ��
APPLICANT ���z �\ (��
(Name) (Phone) � J Z ` 1 �('� —' V lr �.J
(Address) � 2 V� l�� y � J ��� S V� i�`�, J� J��
(Address) (City) (Zip Code)
(Contact Person) � � ��'�� (Phone) 1 JZ� � l
APPLICANT SIGNATURE % DATE � C�
APPLICANT PLEA5E COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom 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
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterati s $4 .50
The Minnesota Statutes § 326B.148 �ost $ Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ S�
until June 30, 2013, STATE SURCHARGE $
The minimum surcharge for a TOTAL PERMIT FEE $ �,�j '
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid �✓ Receipt No. 7 J � y �
�0 S
Date r r)� / I � By
Buildin¢ Official Date � �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372