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� 4 Yittp� Date Rec'd'
CITY OF PRIOR LAKE PLUMBING PERMIT
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PERMIT NO.
s r�a�. �
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ADD S ' . � ZONINCi (ot�« ux�
.
LEGAL DESCBIP'1ZON (o6oe we onir) .
LQT BLOCK ADDITION PID
OWIVER � '
(Name) ° (Phone)�' � ��
<Aaa�> !11 N�.�
��' _pp iance Lc�nnections Inc��
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e, ccur) <z� c�>
�co� P�� 952-445-4803 ��
APPLICANT SIGNATURE � ' ' DATS �
APPLICANT PLEASE COMPLETE BELOW
uan of Firture anfi of Ft:tnre
Bath 11ib with oi without shower Rou -ins
DisMvaeher • Water Heatex '
Floor Drain Wat� Softener
La m Sink Stand ' sshi Machine
La Tra 1 or 2 o- t sink Sewa E'ector
Shower Stall BackIIow Assembi
Sinks Backflow Aesemb Teat
� Bar Sink lawn ' ea
Water Closet oilet ' Other .
FLE SCHEDULE .
Indushial, Commercial & Multi-Pamily lYo of job oost witL a 549.30 mioimnm ResidaNial, N�+v One &'Irvo-Family S 149.50
Residential, Additio� dc Alb�ions S49.S0
77ro Minnesota Statutes § 3268.148 .. w� S Building Permit #
"SURCHARGE" has 6arn d�anged for one
year effective PLUMBING PERMII' FEE S� •
Juty i ..aoio. �tu au�� �. ioi �. STATE SURCFiARGB S.
7ue wisimun:ar�charge kr. "ttrat he^ vermu TOTAI, PFRMIT FEE S
�+� �io�i�g 1. SO7@ _
1'hia ApplksHoa Beoomes Y'oar Baiiding PermH W6en Appreved Paid t � Rec ' No. �
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s.�wa omm� n,a /.
. xa �■oa� �.0 �o� (9n) or�.nsa4 r,� pst� 4n.aaas
4616"Daknh 8'h'eet 3.E., Priw' Lflce. Miorieto2a S!3?E -
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