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0 4 PRip� Date Rec'd
� � CITY OF PRIOR LAKE PLUMSING PERMIT
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1. Blue File pERMIT NO .
2. Gold Ciry /� D p��
3. Yellow Applicant
; lease e or ' t and si at bottom '
ADDRESS ZONING co�ce use)
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LEGAL DESCR�TION (o�Fice use only)
LOT BLOCK ADDITION PID
OWNER � /''�
(Name) VI/ (Phone)
(Address) c� � � �
APPLICANT h�ml� �� U
{Name) pG (]00308 (Phone)
(Address) 651-365-1340
(Address) 367 �a (City) (Zip Code)
` Eagan, MN 55123 '
(Contact Person) �- � � � (Phone)
APPLICANT SIGNATURE � DA'r1? —
APPLICAN LEASE COMPLETE BELOW
uanti T e of Fizture uanti e of Fixture
� Bath Tub with or without shower -
Dishwasher Water Heater
! Floor Drain
Lavato athroona Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
ginks Backflow-Eissembl Te3rt �
; 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 8c Two-Faznily $149.50
Residential, Additions & Alterations $49.50
" " �'ost $ � Building Permit #
j The Minnesota Statutes § 326B.148
i "SURCHARGE" has been extended pLUMBING PERMIT FEE $
until june 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERNIIT FEE $ O
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid� Receipt No.
Date fi � / By
BnIIdine OfScial Date � �7
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ^^
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