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,, ��; �y:�� CITY OF PRIOR LAKE PLUMBING PERMIT G' �. rZ.
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�INNESO��'
' B ''� F "° PERMIT NO. � 2
2. Gold City ,,,
3. Yello�v Applicanl
lease or rint and si n at bottom)
ADDRESS ZONING (ot]'ice use)
172�8 �E�-�;el� ��. �.E.
LEGAL DESCRIPTION (ofiEice use only}
LOT BLOCK ADDITION PID
, �OJ Q �n 0./ Vl a r `t e/�( c� ck a {F�one) 9J 2- 22 ��o Z.S z
{Address) �72.� Deet-F��(d �r . �J,�. �riD� �-0.�CQ �5
APPLIC
(Name) � r0.� v� �IrO ��Uw��JI ti4 � --�kC , {Phone) �. Z �-�o R (o R Q �
(Address) �8 (� 26a"� J � � � . �L�2�/ i � �G� �J�' O �- �
(Address) (City) (Zip Code}
(Contact Person) � ° �- fO {Phone} � � � �' Qq �
APPLICANT SIGNAT ` DATE � ' 1� ' ( �
APPLIC EASE COMPLETE BELOW
Quanti T e of Fixture uantit T e of Fixture
Bath Tub wifh or without shower Rau h-ins
Dishwasher Water Heater
Floar Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laund Tra (1 ar 2 com artrnent sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Siuk Lawn 3 rinkler
Water Closet Toilet) Other
FEESCHEDULE
Industrial, Commercial & Multi-family i% o£ job cost with a$49.50 minimum Residential, New One & Two-Family $ i49.S0
Residential, Additions & Alterations $49.50
The Minnesota Statutes ¢ 32Gf3.1�tR ��st $ Building Permit #
"SURC.I-IARGr" has been changed for one
year effective PLUMBING PERMIT FEE $ �- �{ � 5 0
.D»ty F, 2ni0, ifr�tit :�une 3�, L�1 i. STATE SURCHARGE $ ,�. 0
Tfie minimum surchar�c for x °�xed fec" �crmit TOTAL PEItNIIT FEE $ ��' �.5�
is �;5, beginnin�.)n!y A, 201U
This Application Becomes Your Building Permit When Approved Paid /" �) Receipt No. � D/�
�.7 ,,7 v v
Date n / /L By �
Baildins Official Date y
24 hour notice for all inspections (952) 447-9850, tax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mlnnesota 55372