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Date Recd
04 ?R10 e CITY O F PRIOR LAKE PLUMBING PERMIT
N
v
0 1 God File PERMIT NO. �3 _ Q
1I2 2. Gold City
3. Yellow Applicant
' lease j . e or , ' , t and silo at bottom ZONING (office use)
ADDRESS
' ► AI r. • IA
LEGAL DESCRIPTION (office use only)
PID
LOT BLOCK ADDITION
OWNER (Phone) / �• — 1
(Name) � - • • •
(Address)
APPLICANT AppliatICID Conners Inc.
(Phone)
(Name) ; - -1. ,
. o , - , MN 55379 (Zip Code)
(Address) (Addre 52-445 ' :_s , (City)
(Phone)
(Contact Person) _ II • ' � / 7-• 2-6 APPLICANT SIGNATURE 4 -,ii !�'� DATE
APPLICANT PLEASE COMPLETE BELOW Quanti Quanti - Rou:h - ins T e of Fixture •
T • e of Fixture
Bath Tub with or without shower
_11, Dishwasher -_ Water Softener
Floor Drain 111111111111111111 Stand Pi 9 e W ashin: Machine
Lavato Bathroom Sink Sewa_e Eector
Laund Tra 1 or 2 com • ailment sink —_ Backflow Assembl
i hiviitil imim mm IIIIIIIIIIIIII Backflow Assembl Test
Bar Sink _•■ ,
Water Closet Toilet Other
FEE SCHEDULE
Residential, New One &Twh- Family $149.50
Industrial, Commercial & Multi family 1% of job cost with a $49.50 minimum Residential, Additions & Alterations $49.50
t $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
STATESURCHARGE $
until June 30, 2013, • -
The minimum surcharge for a TOTAL PERMIT FEE $ r ., -moo
"fixed fee" permit is $5.00 ,
Receipt No. 9� �' 7�"
This Application Becomes Your Building Permit When App roved Paid �L� 56
Date 7 D J By AM
Buntline Official
Date 7 /�
24 hour 646 Dakota Street 5.E. Prior 2 Lake, Minnesota -4245
55372
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