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CITYOF RIOR LAKE PLUMBING PERMIT U
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`. smc Far I PERMIT NO. I Z b (� T� I
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'lease pe or ,rant and si.n at bottom 3. Yellow APPiicunl
ADDRESS
J y� / ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER _
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(Name) /t�""J
( 9SZ - / /. T - ot5
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(Address) � ' Z#-- I- ,2 2-c IV/r--.5"37- L
APPLIC '
(Name) L /3 1 ;, h:,.,,/,
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(Address) � �,/ �� ih %it/ �"f�r/
Ar (Address)
(City) (Zip Code)
(Contact Person) s) Afre-- -------' (Phone) 47Z 1, - n4 7
APPLICAN , Sic ATURE �'S� DA'Z'E ����e----
A' ATP PLEASE COMPLETE BELOW
Quanti ' e of Fixture
Bath �'ith or without shower Quantit Type of Fixture
Roush -ins
Dishwasher Water Heater
Floor Drain / Water Softener
Lavato Bathroom Sink) Stand Pi , e Washin: Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks
Backflow Assembl Test
Bar Sink Lawn Sprinkler
j Water Closet (Toilet) Other
FEE Industrial, Commercial & Multi - family 1% of job cost with $49 SCHEDULE �num Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes $ 32613.148 Est $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ f
July 1, 2010, until June 30, 2011. STATE SURCHARGE �
-- --
The minimum surcharge fora "fixed fee" permit �!►Yr�1 �� .0
is 1i, beginning July 1, 2010 T OTAL PERMIT FEE '►! � � it, Y �'
This Application Becomes Your Building Permit When Approved Pail s 1
pp I � WI Recei ► , o.
Building Official Date C Date ,,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372