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,� pRZ Date Rec'd
° � CITY OF PRIOR LAKE PLUMBING PERMIT
� �
��'TrBSd�� �. e�ue F;�e
z. o��d � PERMIT NO. � Z�� J 7
3. Ydlmv Applicnnt
Pleaae ar t and ei at bottom
ADDRESS � ZONINC� (ot1Fce use)
��Z�� ���( Ic�.i �C�
LEGAL DESCRIPTION (oB6ce use only)
LOT BLOCK ADDITION �'ID
�aWNER � ��d ��� � (Phone) �L/ 1 � J� ' �
{Address)
APPLICANT(" �]/,�, ] J/''�/'�/��
(Name) l ° � {Phone) �� / V� / " ! l/LJl
(Address) v � I � � ^ � �� � �-'/
(Address) (City) (Zip Code)
(Contact Person) � �` ` � �-' r � ` �� `� (Fhone) — I J f �-Y� � �
APPLICANT SIGNATURE DATE � � , �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixtare uanti of F�cture
Bath 'Ihb with or without shower Rou -ins
Dishwasher Water Heater GtC �YYt
k'loor Drain Water Svftener
Lavato af.hroom Sink St�nd Pi e ashin Machine
Laund Tra. 1 or 2 cam artment sink Sewa e E'ector
Shower Stall Bacl�low Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Imdustrial, Commercial & Multi-family I°lo of job cosi with a$49.50 minimum R�sidendal, New One & TtvaFamily $149.50
Residentist, Additions & Alberatio� $49.50
T'he Minnesota Statutes � 326I3.]48 ��st $ Buiiding Permit #
"SUKCHARG�" has been changed for one 5�
y�ar ei'fective PLUMBING PERMIT FEE $ �
.TuZv �, ZOIO, until 30 z011. STATE SURCHARGE $
The minimum surchargc for a fee" permit TOTAI. PERMiT FEE $ S�'] • �
is ",�,,i, beginniag 3uty 1.2010
Thts ApplicaEion Becomes Your Bnilding Permit Wl►en Appruved Paid�J /� Recei o. � �-� g/
7�
Date� �-7 �� By
sdildlna o�1 Date
24 hour aotice for all inspectiona (9S2) 447-9850, fax (952) 449-4245
4646 Dakota Sheet 3.E., Prior Lake, Mlnneaota SS372