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CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue Cit y
2. G PERMIT NO. /3 a
Gold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
(A/.!Q -t -3) Ci YC tY
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) N _ VI 4— +�Ld' j R (Phone) 52 '41
(Address) I (01_05 h C V - �e� � G C4c LQ
(Name) APPLICANT (6‘41.. Ili) `l' (f q 0
(Address) f :°/ 0 Lt VP. VIII 110P St I_ IaSfl 10p, V 5,5 0 3
(Address) (City) (Zip Code)
(Contact Person) �j f'1 P 1r1 (Phone) (05 ` I 4 /
APPLICANT SIGNATURE DATE / zo/ i
PLICANT PLEASE COMPLETE
Quantity Type of Fixture Quantity a of Fixture
Bath Tub with or without shower Rou:h -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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
1 ma rippin atiuu DCI.uinva uui iiuitding Permit When Approved Paid 5 -- 7 / `C J - R ceipt No. 6 i 2
Date _
Building Official Date 3 - 2,6
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372