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O 4 YRIp� Date Rec'd
,� CITY OF PRIOR LAKE PLUMBING PERMIT
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�� '. B '"` F ''` PERMIT NO.
2. Gold City /� � /�d 1L
3. Yeliow Applicant T
E88t Ot' t 811d S� 8t bOLtOM
ADDRESS ZONING co�ce,��
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LEGAL DESCRIPTI()N (office use only)
LOT BLOCK ADDITION pID
OWNE ~-�
CI`Tame) YD ^ t � (Phone) ��� ' �� /� ��
(Address)
APPLICANT
(Name) w .. �(y,��y@C�lOIlS ��'1G (Phone)
(Address) 1313 Dar�EtM ��r����
(�O�@e �� (City) (Zip Code)
(Conta.ct Person) (Phone) ___
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APPLICANT SIGNATURE DATE � D
APPLICANT PLEASE CC)MPLETE BELOW
uanti T e of Figture uanti T e of Fizture
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
, The Minnesota Statutes § 326B.148 ►st $ Building Permit #
' "SURCHARGE" has been extended pLUMB1NG PERMIT FEE $
unril June 30, 2013, STATE SURCHARGE $
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid �� � Receipt No. ;/�--�/
5�� T
Date ��, By �
Baitdin¢ Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mlnnesota 55372
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