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pRIp� Date Rec'd
° c� CITY OF PRIOR LAKE PLUMBING PERMIT
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1 A'NEs o
1. Blue File PERMIT NO. ` /
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2 cola city
3 Yellow Applicant l ../
(Please type or print and sign at bottom)
ADDRESS , + ZONING (office use)
' ' 1 I b C9l] / ) 0 1 1 S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) 1 1i i r i . � l l �1 I Phone J L/
r j &?JY f ( ) (Address) l�5 i . 0 l61 0 r c'3 l.- La
APPLICANT
(Name) Appliance C r ; i ectlons I !''y (Phone)
(Address)
(Address) „ " (City) (Zip Code)
(Contact Person) " `.` (Phone)
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APPLICANT SIGNATURE " A /i // 2 . / ` ( ( DATE ( 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
The Minnesota Statutes § 326B.148 m ost $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 5
is n beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid �� Rec: t No. y/ Z
- 7
Date / / B
Buildinis Official Date 2.4..._
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 /
4646 Dakota Street S.E., Prior Lake, Minnesota 55372