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� CITY OF PRIOR LAKE PLUMBING PERMIT ���— �Z
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'�'�v►v�s�° '. � �° PERMIT NO.�Z , L�Z�
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ADDBESS � / p� ZO1�TII�T(� (�5oense)
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LEGAL DESCBIPTION {�oe we rnily}
008' D�
LC7I' BLOCK ADDTTiON PID
OWNLB /'�� �_
(Name) L�I,�L�l�C��'� � �eQ �I�c/�— (Phone) �o� `��_`�l'
c�) 3 $ , , ,.
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(Adcfiress) 5�,��n ��
(Addxess) (City} (Zip Code}
(Contact Pezson) (Phone}
APP'LICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
tt T o[ F�xtnre anti of Ffatare
Bath T�b wifh or without shower Rou h-ins
�--� Dishwasher Water H�ter
Floor Urain Water Soi�ener
La.vato Sink 5faud Pi ashi Machine
La Tra 1 or Z ar�nt sink Sewa e E'ector
Shower Stall Backflow Assembl
� Sinks Backflaw Assemb Test
Bar Sink L.�wn S' e�r
Water Cioset oilet Other
FEE SCHEDULE
Indt�strial, Commetcial & Multi-family 1% of job co� with a$49.5fl miaanum Residential, New O� & 1�vo-Fmnily S I49.50
Re.siden#iat, Additiops 8t Alteratians 549.50
Thc Minaesota Statutes § 326B.148 �� s �� Pextnit # �
"SU[tCHARGE" has been chang,,ed for one
ycar effective PLUMBING PERMIT FEE $ � s�
.Tuty t, 2010, until dune 3fl, �lit I. STATE SURCHARGE �
The miaimuni aarchar�e tor �"frxed fce" permi; TOTAL PERMIT FEE $
� � �h��ac ao� i, amo
This AppliGatbn Be�wmes Yoar Building Perrait When Approved Paid�� � Kecei No. ���� �
�aa� o�� n,�
�5 . /S • /Z By
24 6oer eotice for all in�pec�ioue (952) 447A85@, fsz (952) 447-4245
4646 DskMa Street 3�., Prlor Lske, Mlnneeeta SS372