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O � PRIp� Date Rec'd
�, CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B '"� �"` PERMIT NO.
2. �,� ��Ty /Z� �o�
3. Yellow Applicant
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ADDRESS ZO1�iING cot�ce ��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION pID
OWNER i '�`,,
Cj`jame) J�� � � (Phone) ��'�:�'?�(1/ �t�
(Address)
APPLICANT
(Name) (Phone)
nect�ons �c.
(Address) 12A50 Chestnut Bivd
(Addr �, (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNA . DATE d' '
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture u�nti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e ashin 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 $49.50
The Minnesota Statutes § 326B.148 t$ Building Permit #
"SURCHARGE" has been extended
until june 30, 2013, PLUMBING PERMIT FEE $
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�� / r/'� Receipt No. /��/1 /
� f _ ,� �� � 7 f
Date l L � By
BuildIn¢ Of�icial Date
24 6our potice for all inapections (952) 447-9850, fax (952) 447-4245
A646 Dakots Street S.E., Prior Lake, Mianesota 55372
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SOSA-CA�-S�e .