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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File pERMIT NO .
2. Gold City /Z .. ) �`�
3. Yellow Applicant L v
lease or ' t and si at bottom
ADDRESS ZONING (ott'ice use)
I`� 1 �.3 T" Q� � V 1 e-�..1 c`r� .SS3 7
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER /�
(Name) Q°��n l�lw a � 2a! (Phone) � I - '7 5 �O - q i � `1
(Address)
APPLICANT
(Name)_�,��cl a!!N W�1TFR C;(�Nf)ITIONING (Phone)
6030 CULLIGAN WAY
(Address)
(Ad �) 9 3�_7�04 (City) (Zip Code)
�.�...
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE � U'�" �' ��
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishv�asher 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
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
- �°�---°�` f '� - �;t $ �O � 0 � Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ �q ��
until June 30, 2013, STATE SURCHARGE $ . S, o(� �
The minimum surcharge for a TOTAL PERMIT FEE $ �Sy, .5�
"fixed fee" permit is $5.00
rt►is Appucanon Becomes Your 13uiiding Permit When Approved Paid �, J� Receipt No. /�� U
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Date � �/ By
Buildin¢ Ofticial Date
24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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