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CITY UF PRIOR LAKE PLUMBING PERNIIT
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�+tsso�� i ao�"ia � PERMIT NO. [�'� I ' 1
A Ydlow Applica�e / � � / '� �
Od' 8Ld St �10ttOID
Ann�ss zorm�G c� �,
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LEGAL DESCBIPTION {oB6oe,ue only)
LOT BLOCK ADDITION FID
OWNER /
{Name) G Gc � / �/0 �/�+� (Phone)
tA�)
(Name) � Sc �i+e de / / "�h i � ('/ � ' �� 1� '� �`'.3
(Aaa�} r S� ¢S /2� � da/�j �'� /�L � �3� Z-
(Addx+ess) t�Y) (�P �} -
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Ar�.rc�rrr szcTriA� nAZ� 'S / y i 2
APPLICANT PLEASE COMPLETE BELQW
nti of l�iz#are fi of Ffztare
Baxh 'l�b v�ri#li or �vithout slrower Rou i�
Dishwasher / Water Heater
Floor Drain � Wat� So�er
L� nfhroom Sink Stand Pi ashi Machine
La Tra. 1 or 2 armie�nt sink Sewa E'ector
�� � Bacl�ow Assembl
s� Backflow Assemb Test
Bar Sink Lawn S �nkler
Water Cioset oilet ��
FEE SCHEDULE
Indastrisl, Commercial & 1Kult�famiiy 1'1a of job co� wit� a$49.50 minimnm Reaid�ntial, New One & Two-Family S149S0
R�tiat, Additi�s 8c A16aratians 549.50 .
' . " � S Building Pea�nit # � .
The Minncsota Statutes § 326B.148
"SURCHARGE has been changed for one PLITMRINGPERMIT FEE $ �� s � .
yr.ar efiY'ective
Ju1y Y, 2pI0. uAtii June 30 zot �. STATE SI7RCHA.RGE $ �
77�e miaimn� sarer:rge ror a°rizea rec" permit TOTAL PFRMiT FEE $ �"�.
is � 3aly 1. Z�I� -
This Applicttioa Be�omea Yoar Bu�ing Permit W�� Appreved Paid �� S 2� R' No. � S�J ��
� omcw � � S�. /Y. � Z� .
24 Leor �Nax fsr aN io�es (932) 447 985Q faz (952) M7-4245
46�/6 Dakota Shee� 3 S., Prior I.ake,llRinttesota SSi'12