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� CITY OF PRIOR LAKE PLUMBING PERMIT
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'. B '°e �"` pERMIT NO.
2. Gold City f� �--� � u
3. Yeliow Appiicant
lease or ' t and ' at bottom
ADDRESS ZONING �ot�ce ��
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LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION pID
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(Address) ^ ��
APPLICANT � � \�,
(Name) (Phone) �` �--J���� ��� �
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(Address) ` �
„(A�dress) (Ci (Zip Code)
(Contact Person) � (Phone) ��` ���/�
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom 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, Commercial8c Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residentiai, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended PLUMBiNG PERMIT FEE $ �����
utYtnl Jtane :�0 2013, STATE SURCHARGE $
'C'he minimum surcharge for a TOTAL PERMIT FEE $ �' .
"fixed fee" permit is $5.00
1 u!� AiJ�ql�.A41VL DLT.V��1CD � vuc-�uilding Permit When Appraved Paid �� � Receipt Na ��� �
Date i � // By
Baltdin¢ Ofticis! Dxte /
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minpesota 55372 ,�,f 1
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