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O � PRIp� Date Rec'd
� � CITY OF PRIOR LAKE PLUMBING PERMIT � , �,�
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_� � 1
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,. a,� Far pERMIT NO. j I
2. Ootd Cily /�. _ �� I�
3. Yellmv Applirnn� . .
leaae e ar and sign at bottom
ADDRESS ZONING (otCice uge)
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LEGAL DESCRIPTION (oH'ice use only)
LOT BLOCK ADDITION PID
ow�x, �'�el� �
(Name) •�C� h cl .s. Q�� . (Phone) � / a - � � S o� . (P �-
(.�.�idress) I S 3 5� r r �. Cn� � S���
APPLICAIYT�
(Name)� r r r v�?� �.r,�LQ a '' p � u�n-, ��_, �'n.l'_ {Phone) � Co3 � �-'� ��, �
(Address) �oa � n���h S+ �,r,o �� 55303
(Addxess) (City) (Zip Code)
(Contact Person) � � �c� {Phone) � l0 3 ` S� � — � g g O
APPLICANT SIGNAT��--- DATE �� 1" / a1
APPLICANT PLEASE COMPLET.� BELOW
Quand T e of F�xture uantlt e of Fi�cture
Bath Tub with or without shower Rou h-ins
Dishwasher / Water Heater
Floor I?rain Water Softener
Lavato Bathroom Sinl� Stand Pi e ashin Machine
Laund Tra 1 or 2 cam artment sink Sewa e E' ector
Shower Statl Backflow Assenrzbl
Sin�CS Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toitet) Other
FEE SCHEDULE
Tndustrial, Commercial & Multi-family 1"/0 of jab cost with a$49.50 minimum Residential, New One & Two-Family $149,50
Residentia[, Additions & Alterations $49.50
The Minnesota Statirtes $ 325I3.]4R ^ � S � $ Building Permit #
"SURCHARGE" l�as been changec[ for one pLUMBING PERMIT FEE $ • J�U
year effective
.r�,�y �. 2�yo. ,���;; ,��ne 30, ��,. STATE SURCHARGE $ .50
The miaimum sorcharge tor � "Fxe4 i'ee" perneit TOTAL PERMIT FEE $ .�� �0
Ic �, beginaing duly 1, 2UlU
�
This Application Becomes Yoar Building Permit When Approved Paid� ,/ s� R ei t No. �_� Z�
��
Baildine O�icial Date D `�', Zf . iL �
24 hour notice for all inspections (952) 44'1-985Q, fax (952) 447-4245
4646 Dakota Street S.E., Pr1or I.ake, M9nnesota 55372