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Date Rec'd
���� ���:� � CITY OF PRIQR LAKE PLUMBING PERMIT
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•�. B��r File pERMIT NO.
2. aoia c��y � Z � � �
3. Yellorv Applicun�
lease or lnt and si n at bottom
ADDRESS ZONING (ot�ice use)
Js 1� � C�r�r�v.�-� v r, s �
LEGAL DESCRIPTION (oE]Eice use only}
LOT BLOCK ADDITION PID
OWNER ,�-
(Name) / /' O ��, 1'' 0 �.V � (Phone � / 6 /2� � 6 q � s �
(Address) �- V /�/ r ' S
APPLICANT,� ,/��
(Name) �� � �Z! 0 �rt./�1 (Phone) qS� - �4{3 - =S�.S.S
(Address) �5,�3 1��`.eh, �n_c.- �1�P ��/�r/ �r�C�►�—�� ���72
(Address} (City) (Zip Code}
(Contact Person) �'�U �i �rr�..�✓n (Phone} ��� ' 66 �/ /4.�-S"
APPLICANT SIGNATURE � DATE � '' ��� �
APPLICANT PLEASE COMPLETE BELUW
Quanti T e of Fixture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floar Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laund Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Bacl�low Assetnbl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
Industrial, Commercial & Ivtulti-family 1% of job cost with a$49.50 minixnurn Residential, New One & Two-Family $ I49.50
Residentiat, Additions & Alterations $49.SQ :
"fhe Minnesota Statutes � 326f3.148 � �st $ $uilding Permit #
"SURC..HA.RCr1.;" has been changed For one � y�
year effeetive PLiJMBING PERMIT FEE $
.ls�1y 1, 2011p t�ntii 3une 3i1 20� ➢. STATE SURCHARGE $ S- ��Q_SD�
'I'fie miaimum xtirchnrge 1'or a "fized Pce" permit TOTAL PERMIT FEE $ �
ig:�, begioning.iuly 1., 2Q10 —
This Application Becomes Your Building Permit When Approved Paid �,/�—z� Rec Na � 7� �
�
Date � - �/. . � B
Buildina Otflcial Date '
24 hour notice for a!1 inspections (952) 447-985Q, fax (952) 447-0245
4646 Dakota Street S.E., Prlor L�ke, Mlnnesota 55372