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,� CITY OF PRIOR LAKE PLUMBTNG PERMIT
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,. a�� File PERMIT NO. '� � (��
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3. Ytllow Applicanl ��
lease or rint and si n at bottom
ADDRESS ZONIlVG (or�c� �)
� oU�-�P� � � cf, �-
LEGAL DESCRIP'I'ION (oflEice use only)
L�T BLOCK ADDITION PID
OWNER/�� (� )
(Name) T11�'1 �f 1/C�ca�J � E,'-1 Sc) /l.� (Phone) �oZ - oZC�D - a 9 6 D
{Address) ot U ��c, Gy7 (S (�-� /��'
APPLIC���I ' � oZ "o�OO 'O O ��v
(Name) e/✓� �..� �` ���(.1� (Phone) �
(Address) � � � �l.�C�SC� /�/� #y �� !G-t V� _ �� �.33�
(Address) (City) (Zip Code)
(Contact Person) a. � � � {Phone} �o�,� - oZ b�U - �O �
APPLICANT SIGNATURE �� DATE � 1 �
PLICANT P.LEA5E COMPLETE BELOW
Quanti T e of Fixture uantit e of Fixture
Bath 'I�ib with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e Washin Machine
Laund Tra 1 or 2 com arkment sink Sewa e E'ector
Shower Stall Backflow Assernbl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
Industrial, Commerciai & Multi-family 1% of job cost with a$49.50 minnnum Residential, New One &'I�vaFamily $149.Sa
Residential, Additions & Alterations $49.50
Thc Minnesota Statutes � 326B.14R ��st $ $uilding Fermit #
"SURC.I-IARGE I►us been chan�ed fi>r one PL��G PERMIT FEE $ `� ���
yeAr effective
.Tuty i,'2010, until:7une 3Q, 20! 1. STATE SURCHARGE $ .�.�
7'he minimum sarchargc for s °tixed tee" permit TOTAL PEItNIIT FEE $ ,'�y �S�
is �, beginning.luly 1, ?010
Thls,Application Becomes Your Building Permit When Approved Paid y, � R eipt No. -, /(,�
✓ . �yr
Date f _ -� � �-
BaildlnH Offlcial Date �t�
24 hour aotice for all inspectione (952) 447-9850, fax (95Z) 447-4245
4646 Dskote Street S.E., Prlor Lake, Mlnnesota 55372