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r RIO OR LAKE PLUMBING PERMIT NOV 1 `5 2011
o � CITY OF PRIOR
H� BY ...
...... v ° , -- Pi le PERMI NO. / 1. f Z
I. Bl
y, Blue City
INNESO�P 3. Yellow Applicant
ZONING (office use)
Please ii • or .riot and siIn at bottom)
ADD ' _ , G �� o at 11. = ,5 1�.11aia -1
LEGAL DESCRIPTION (office use only) PID
LOT BLOCK ADDITION
OWNER
(Name) (Phone)
(Address)
APPLIC , • 1 ..1 i_ ' . A1�1 ° ` ) ‘" l l ' (Phone) (Name) / ' u 1._....14. /1A .
(Address) l �S� ,,
4 (City) (Zip Code)
(Address) � .
(Phone) ,
(Contact Person) 1..0.,...
1 ■ 1 ��...,.. .1 DATE �i
APPLICANT SIGNAT • AMP. ''�
APPLICANT PLEASE COMPLETE BELOW ,P e of Fixture
Quanti T , e of Fixture Rou:h ins
IIIIIIOM Bath Tub with or without shower 11111111111111
Dishwasher Water Softener
Floor Drain 1111111111111111
Stand Pi s e Washin: Machine
IIIIIIIIIIIIIMIII �� Lavato Bathroom Sink) Sewa� e E�ector
Laund Tra (1 or 2 com.artment sink Bac E Assembl
MIIIIIIIII Shower Stall Backflow Assembl Test
IIIMIIII '
Lawn Sprinkler
Bar Sink Other
M Water Closet (Toilet)
FEE SCHEDULE
1% of job cost with a $49.50 minirnum Residential, New One & Two - Family $149.50
Industrial, Commercial &Multi Multi-family Residential, Additions & Alterations $49.
)st $ a
Building Permit #
The Minnesota Statutes § 326B.148 PLUMBING PERMIT FEE $
"SURCHARGE' has been changed for one $
year untii June July i, 2010, unfit :lone "fixed f i i• STATE SURCHARGE
The minimum surcharge for a "r'e uee" permit
TOTAL PERMIT FEE $
is g, beginning inly l., - ipt No / - (
mac: tii
:. ii es Your Building Permit W en Approved Paid . r- (�/Ct
This A � '� -� ZL (� Date (U t
�II�`! �• Date
Building
Milo:" 447-4245
24 hou46 Dakota Street S.E.nPr or Lake, Minnesota 9 55372
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