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,� �:.- ��� CITY 4F PRIOR LAKE PLUMBING PERMIT ,
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�jNNES��� t. Blue F;le
s. aoia c;� PERMIT NO. �� C��
3. Yelimv Applicanl
lease or t and si at bottom
ZONING co�e� ��
�D�SS 31 L--1 c � �; �� R��IS e C�u r-� �v �
LEGAL DESCRIPTION (office use only}
LOT BLOCK ADDITION FID
�aWNER �r 1 S S��c/�'� 1 � J`� c7Y1�1 (Phone) >� �J� ���
{Address) 3�`� l.P �JJ 1l Gl � t ,� N l�V ��,� ��t
APPLI T s — U / / /
(Name) �� 'Pl � ��LY S �� ' "k {Phone) � � y y 7 C. L t�
(Address) 1 ��� W • (�t2_� K�l� �l/`O��wD...,c.� �.�•�..� 1 �J
(Address) (City} (Z�p Code)
(Contact Person) D (Phone) `� S� �7 �,� y � � �
APPLICANT SIGNATUIZL DATE
APPLIC.ANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanf3 e of Ffxture
Bath Tub with ar without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato af,hroom Sink Stand Pi e ashin Machine
Laund Tra 1 or 2 com artment si.nk Sewa e E'ector
Shower Stall Backflow Assennbl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimu►n Residendal, New One & TwaFamily $149.54
Residential, Additions & Alterations $49.50
Tha Minnesota Statates $ 326B.]48 � $�Wo Building Permit #
"SURCHARGE" has been changed for one pLUMBING PERMIT FEE $ ��'1 •�
year effective �
.Tui,y i, 20i0 untit ,7une 30 z0i i. STATE SURCHA.RGE $ S• s� .�'A
The misimum surcharge far a "tixed fee" permit TOTAL PERMIT FEE $�S� • Sb
is �5, beginaing July 1, 2Q10
This Application Becomes Your Building Permit When Approved Paid �„�.—, l� Rec pt a��-7�
�'
Date �. . 13 , � Z By
Buildins Oificial Date
24 hour noHce for all inspections (952) 44'1-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prlor Lake, Minnesota 55372