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PRIG Date Rec'd
• CITY OF PRIOR LAKE PLUMBING PERMIT
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INNESdSP I. Bloc File
2. Gold City PERMIT NO. /0
3. Yellow Applicant l[ `
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/ ).-. 4 410 c pr - ; n1 La F--0
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) V el 4 1 r ! 16 14,e, (Phone) 95. cfq6 - Nett/
(Address) cSL � e. 1 ' i' N " '7
APPLICANT { , ( � � ( (Name) _ � . �1 '� .�. � Q ♦ . A/ 0 E 4n (Phone) O"�
(Address) 1144 cal g_a - l' n I' NL - 1
( `C
(Address) tkCity) (Zip Code)
(Contact Person) 0) (Phone) ------ ' CC 7 1 � v
APPLICANT SIGNATURE _. DATE 9_ 1- \ 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater
Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
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 & Alterations $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148 PLUMBING PERMIT FEE $ -1 oi - so
"SURCHARGE" has been extended STATE SURCHARGE $ .50
until June 30, 2013,
The minimum surcharge for a TOTAL PERMIT FEE $ °M1IGIP
"fixed fee" permit is $5.00
____ _ .....iding Permit When Approved Paid ..1..1 ` s- Receipt No. t g I/A
Building Official Date D to 2--"1/11 / 1 3 B d g
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 �p i r5
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 (�^
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