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(;I') RIi Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
-
41 /n'NESD` 0P
1. Blue File PERMIT NO
2. Yell City NO. p l — 449 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS l � 2 5 / ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone) q a Co 3 u 7 q
(Address) 11 3 (ac l ; m . / 6
APPLICANT
(Name) Appliance Connections ! : (Phone)
(Address) 1313 r: ';;‘:RA C'
(Address) Shakopee ) (City) (Zip Code)
952
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater
Floor 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) Other
FEE SCHEDULE
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 )st $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ • .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ Z11. i
is $S, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid _ 9f, 5 - 2 , 2 Rec No. G 7i23
Date , vl, / / By
Building Official Date (/ . 1. .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 1
4646 Dakota Street S.E., Prior Lake, Minnesota 55372