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,� -�� u_ � CITY OF PRIOR LAKE PLUMBING PERMIT ��.,. � Z
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�. 8�,� File PERMIT NO. JZ .
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3. Yellmv Applicunl
lease or rint and si at bottom
ADDRESS ZONIl�TG to�re �)
02 B�) lv �x I ra �� 1 N w
LEGAL DESCRIPTION (ot�ice,sse only)
LOT BLOCK ADDITION PID
�� m 1 C.hG 2. � L-:� S-��P.� (Phone) GI � a� �� 3o�n J
(Address) o� g y�o x�Y Q, �� � }J w.
APPLICANT • �
(1�ame)f`n`Y1neSo►�z� Pl v�s�_� V� La�� (Phone) c 7S�d L I `�J�' `I �`/ �/
(Address) ��'� w' 3 � �-Q, sha-1'�'°Q''-�- S���
(Addxess} (City) (Zip Code}
(Contact Person) ��(. Su � d PQXY+ (Phone) �'� a' �'J'� J' y N�
APPLICANT SIGNATUR� ���� DATE ` `� � � Z
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti e of Fixture
Bath Ttxb with or without shower Rou h-ins
Dishwasher Water Heater d
Floor Drain Water Softener
La.vato athroom Sink Stand Pi e ashin Machine
Laund Tra 1 or 2 com arhnent sink Sewa e E'ectar
Shower Stall Backflow Assennbl
Sinks Back£low Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other QS t n�t, f
� 1m-�- � Cr� � �e.rL.
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost wiih a$49.50 minimum Residendal, New One & Two-Family $149.50
Resiciential, Additions & Alterations $49.50
The Statutes § 326B.148 �?st $ Building PermiY #
"SURCHARGE" has been ch�nged for one
year etfective PLtJMBING PERMIT FEE $
•h�1y i, 2Q10 antil3une 3fl zOt �. STATE SURCHARGE $ .50
The minimum surcharge for s"fixed fee° per TOTAL PERMIT FEE $
is �, beginning Juty 1, 20]0
This Application Becomes Your Bnilding Perrnit When Approved Paid J TG f��J Rece' No. �� �?
' J
Bailding Offidat Date Date� `� �� B ,
24 hour not3ce for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Pr3or Lake, M9nnesota 553'I2