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� PRIO Date Rec'd
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�, '�; :, �. `� CITY OF PRIOR LAKE PLUMBING PERMIT
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' B'"` F PERNIIT NO. � t- / S! �
2. Gold Ciry
3. Ydlow Applicart
OT iiIItalOd � atbOLtDm
� ZONING (oH'ice use)
(S/ � ^ � � �
LECrAL DFSCRIPTION (office use only)
LOT BLOCK .ADDITION PID
OWNER �� ",
(Name) l9" �� r'��.�1� ��`-S �' (Phone)
(Address) �
• `[ � i v �
APPLICANT .
(Name) (Phone)
(Address) on Avenus
�,�p�, MN (City) (Zip Code)
��1-�
(Contact Person) (Phone)
APPLICANT SIGNATURE AATE
A►PPLICANT PLEASE COMPLETE BELOW
� of Fizture uanti T of Fiatare
Bath Tub with or without shower Rou -ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato throom Sink Stand Pi e Washin Machine)
La.un Tra. 1 or 2 com artment sink Sew e E'ector
Shower Stall Backflow Assembl
S� Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet (Toiiet ��'
FEE SCHEDULE
Industrial, Commercial & Multi-family I% of job cost with a$49.50 minnnum Residenrisi, New One & Two-Family $149.50
Resid�tial, Additions & Alterations 549.50
g�� � $ Building Permit #
PLUMBING PERNIIT FEE $
STATE SURCHARGE � .50
TOTAL PERNIIT FEE $ �S� <,�—
(06a Use �iy)
This Application Becomes Your Bnilding Permit Wlien Approved Paid �-- � Receipt No. / 7 ��
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Date � BY
g pg�� Date
24 6oar notice for all inspectioas (952) 447-9850, faz (952) 447-41,4'S
4646 Dakotx Street S.E., Prior Lal�e, Minnesota 553T2