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H o CITY OF PRIOR LAKE PLUMBING PERMIT
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�'jNxESOl� I. Blue File PERMIT NO
2. Geld Applicant
NO. /2 ,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
NIG8F Ce- .r ∎nv L AJ
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT
(Name) P r 4 . r c r I ., , , .. �� -� �` L - (Phone) 9s 4 41 - 516
(Address) 3 L AO 0 H : P 6 % T `T'" -, 1 Pr ∎ o r 1.---12-L X5 - 1
(Addkess) (City) (Zip Code)
(Contact Person) 0 --■ C10-) .. i• - • (Phone) co % - 46 5 - 9)-(4`‘
APPLICANT SIGNATURE i DATE -
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 1 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
"SURCHARGE" has been extended ;t $ Building Permit #
The minimum surcharge for a
"fixed fee" permit is $5.00 PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ i ti
(Office Use Only) �
This Application Becomes Your Building Permit When Approved Paid G/ 4 0 Rece p No. 6 g l j
l
Date Z Z l B y
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372