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� pRio Date Rec'd
° � 9 CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B'°e F"e pERMIT NO. ',?�`
2. Gold City
3. Yellow Applicant
lease e or 'nt and si n at bottom
ADDRE$S ZONING (office use)
5l� l 1 50 � �
LEGAL DESCRiPTION (office use only)
LOT BLOCK ADDITION PID
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(Address) � lQ �, � t5��'h �
APPLICANT T (� ,
(Name) 1 Q C� � �S J� . (Phone) "15 � ` � `'C�'� �
(Address) ` `� �.4 � � � ��� � �e ��- / 9
(Address) (C ty) (Zip Code)
(Contact Person) � (Phone)
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APPLICANT SIGNATURE DATE " 7 �y���
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
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 �ost $ V Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $
until June 30, 2013, '
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid� � Re e' t No.� �(�
v
Date � �� �
Buildina Ofticial Date '
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372