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,° � CITY OF PRIOR LAKE PLUMBING PERNIIT
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'��vnr�eso��' '. � � PERMIT NO. � 6 7�
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A Yellm� npq;cmu
1l88C 02 8rid at �IOtYODI
ADDRESS ZUIVING tot�x�e use�
S �r c�' r��--
LEGAL DESCRIPTION {oB6ce use only)
LOT BLOCK ADDITION PID
OWNER
{Name) � O (Phone) SoZ - O � .s
cAaa�s) 3S e � ` /� S
APPLICANT � `_ U
(Name) 1 1'V� �5��1�tC.�, � '�'y �1.� F'Y�U i V1C0 (Phone} 1 `� � � �J � y".> �
(Address) .`> � � e n�Q �/ r�u e �s��� , rn n.d .�s 3 b q
(Address) (City} (Zip Codej
{Contact Person) J � �� Y�� �'�C� (Phone) � YY�Z
APPLICANT SIGNATURE DATE �
APPLIC PLEASE COMPLET� BELOW
Quanti T of Firiure uanti of Fixtore
Bath T�b wi� or without shawer Rou -ins
Dishwasher Water Heater
FIoar Drain Water Softener
La.vato athroom Sink Stand pi ashi iVlachine
Laun Tra 1 or 2 com ar[ment sink Sewa e E'ector
Shawer Stall Backflow Assembl
su►�cs Back#low Assemb Test
Bar Sink Lawn S' er
Water Ctoset oilet p��
�ZE SCHEDULE
Indushiai, Commerciat & Multi-family 196 of job cost with a;649.50 minimum Residet►tial, New O�e & Two-Family $149.50
Re.aidential, Additions & Al2eraaoffi �49.50
7'hc Minnesota Statutes § 326B.1dR ..�� S Building Psrmit #
"SURCHARGE" has been chengec{ for orte
year eflFective PLIJMBING PERMIT FEE $
.Tuty � 2Qi0, unii} June 3fl �ot i. STATE SURCHA.RGE $ .50
The roiaimu� s�irebarge fa. s"tixetl fee" p�J� TOTAL PERA�IIT FEE $ �y"� �
is �i. begfaniag Jniy 1. 2fq0
Thts Applie�tion Becomes Your Bnilding Permit When Appiroved Paid ��/ � R�ei o.
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TA 6onr aoHce for ali iospectioes (952) d47-485Q, fax (952) 447-4245
4646 Daketa Street S.E., PrIor Lake, Minnesota SS372