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,�� �� � CI OF RIOR LAKE PLUMBING PERMIT
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`. a,� F,�c pERMIT NO. �,��(.�
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; 3. Yellow Applicanl �
' ease e or r3nt and si n at bottom
' ADDRESS ZONING �o�rce ��
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LEGAL DESCRIPTION {office use only)
' LOT BLOCK ADDITION PID
' (Nam ) ��''��'�/ G�'�W1✓ (Phone) ��� Z�3 ' O �/�
(Address) � 9 � M �. . � G' ✓ i' !/ G✓ ��y. G-� �- /f� �J�
' APPLIC /��
, (Name) G � � � 1 /t«-+��� �• {Phone) L�Z•�Z'.��rz
(Address) �� �� U v �(/ �Z%istrr.�� � r!l�� �✓—��/
{Address) (City) (Zzp Code)
(Contact Person) � l�L�- i (Phone) �/Z �L `�`� L--
APPLIC S ATURE DATE 5�����
CANT P.LEASE COMPLETE BELOW
uanti e of Fixture uantit e of Fix#ure
Bath �th or without shower Rou h-ins
Dishwasber / Water Heater
Floar Drain Water Softener
Lavato Bathroom Sink Stand Pi e ashin Machine
Laund Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflaw Assembl
Sinks Backflaw Assembl Test
Bar Sink Lawn S rinkler
Water Ctoset Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residentisl, New One & TwaFamily $! 49.50
Residentia[, Additions & Alterations �49.50
"Fhe Minnesota Statutes § 326B.148 � }st $ Buiiding Permit # �
"SURC.HARGE" lias been changed for one g v
year effective PLUMBING PERMIT FEE $ / r �
�Ta�t} i, 20itt, u��tit .�uae 3fl zo� i. STATE SURCHA.RGE '�
The minimum snrcharge for a"Eixecl fee" permit TOTAL PERNIIT FEE
is '�5, beginiiia� JuEy 1, 207Q D
This Applicatiou Becomes Your Building Permit When Approved Paf� N 2 1 20 �2 Recei No.
Date By
Buildlns Otficial Date B �
24 hour noHce for all iuspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372