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°�" �� CITY OF PRIOR LAKE PLUMBING PERMIT
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� 1. alue File
z. aoia c��y PERMIT NO. �Z r �� �
3. Yellmv Applicem
Please e or int and si n at bottom
ADDRESS Z�NING (office use)
5�� N �,� P��� �r N �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION P�
ovvivER 1,._.�, �} N���-1►� � Q n1
(Name) (Phone) � 1 � � � — `� l r�
{Address) � � � (' [ � !v � i �► "[.-- °��� � � 1�, �i� �
��LI��CANT ��� ���il'l� ►� � � 1 � . (Phone) �� �����
(Address) 2 � �O� �. W I V CC.G� "r �'A Ufi� � '
(Address) {City (Zip Code)
(Contact Person) 1 fl � � (Phone) (1"/ � �' `-� � � '�- / `'� �
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APPLICANT SIGNATURL DATE
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uantit T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floar Drain Water Softener
Lavato Bathroom Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stal! Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family t% of job cost with a$49.50 minimum Residential, New One & T�vaFamily $149.50
Residential, Additions & Altetations $49.50
The Minnesota Statutes § 326B.]48
' "' ist $ Building Permit #
"SUitC..l-IA.RGfi" has been chan�ed for one pLIJMBING PERMIT FEE $
year effective
.Iuly �, 2pt o, ifz�tii .tune 30, z0! i. STATE SURCHARGE $ .SO
7'he minimam sarcharge for a "tized t'ee" permit TOTAL PERMIT FEE $ S�'�l )
is ;i, beginning.)uly J..20]Q
This Application Becomes Your Bnilding Permit When Approved Paid �� /, t ---� Recei t o. �� ��
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Date �_ 3. I j.� BY
Buildln8 Otfk3al Date
24 hour aotice for all inspections (952) 44?-9$50, f�x (952) 447-4245
4646 Dakota Street S.E., PrMr Lake, Mlnnesota 55372