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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City PERMIT NO. u ., 1 aw l
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3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Liz/ 70 - k E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I Z B 19-770‘)
(Name) nil tp ` l (Phone)
(Address) �ar f'C.i ?AU wk,Vki 1 V v � ` . 33- a
APPLICANT
(Name) (M ampi® , Piumbing (Phone)
#5 61770 -P
(Address) 61-3 -13
(Ad* sq ' 0 Do Rd. (City) (Zip Code)
g n, MN 55123
(Contact Person) (Phone)
APPLICANT SIGNATURE ,./_/' .%��% DATE
4
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher ( 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
The Minnesota Statutes § 326B.148 st $ Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ . f ' o SC
until June 30, 2013, STATE SURCHARGE $
The minimum surcharge for a ST 5
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ o
This Application Becomes Your Building Permit When Approved Paid 5 4 co R eipt No./_ 10 0
Date No.(0 V
Building Official Date 1 1 - ?A,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 10011
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