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Date Rec'd
4 r RIO CITY OF PRIOR LAKE PLUMBING PERMIT
i
INNESe 1. Glue File PERMIT NO. / / , ni i
2. Gold City
3. Yellow ApplicaN
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
1 � & cL n
( -P 59 I arbc3r mo 11 )
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Q\cti.e, Q YC ,C)./N... (Phone)
{Name) I T 1 l j '��
(Address) `oS9, , ttGt k n� e.c L i
APPLICANT
(Name) o.1L2.. i �� Iai (Phone) 9 , - ( .91-- , • •
(Address) p t7 2,' .re.."_. Af`e ` ��c, .Q . .
(City) (Zip Code)
(Contact Person) I lk & (Phone) QI f- - e°fv-) bck.)
APPLICANT SIGNATURE \ Cum_ u -- DATE /0 - 06-if
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
(
Dishwasher Water Heater
FIoor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
} Water Closet (Toilet) i Other
FEE SCHEDULE 1 - �Cit I
Industrial, Commercial & Multi - family 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148
' " ist $ Building Permit #
"SURCHARGE" has been changed for one
year effective `� PLUMBING PERMIT FEE $ q9 ,so
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 0
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ - 5
is 33, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372