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CITY OF PRIOR LAKE PLUMBING PERMIT T
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2.t.Blue File -��
Zed 'Zy PERMIT NQ./ frrn
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
-7 4S (1&* // ° fav`
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER (� .1/,,']
(Name) IY W A- ►` (Phone)
(Address)
(Name)
APPLICANT al, -�a.G £. U (Phone) 6 l 2 rbc 7
(Address) y �— d -bk 41/4-- 41 4/&/
(Address) (Ciity (Zip Code)
(Contact Person) gd-kra1te'`-4 (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain / Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
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 $ ! -fU Building Permit#
"SURCHARGE"has been extended
The minimum surcharge for a PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ S Y, S7�
This Application Becomes Your Building Permit When Approved Paid ipt No. CV"
Datesi l
Buildine Official Date Z1
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 /
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372