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VR1 Date Rec'd
° CITY OF PRIOR LAKE PLUMBING PERMIT
aiINNES 0 0P I. Blue File '�
2. Gold City PERMIT NO. j + i 5
3. Yellow Applicant I `
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
aUIO jilY15 Lcike SW
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER (�, ( �
(Name) n r\ 5 1 1 L.tu -I 1 coAr)` (Phone) q5a . a 3 3 85
(Address) CD 100n9K W
f, Rd 5
APPLICANT V Appliance Connections lc. ;
(Name) (Phone)
1313 Dania Cr
(Address) Shakopee, MN 55379
(Address) 952 -445 -4803 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE --t_f p DATE /0 - 3 I -1 /
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher / 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 extended PLUMBING PERMIT FEE $
until June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 54. 5()
This Application Becomes Your Building Permit When Approved Paid j �j/ Rece t Nc _
Buildine Official Date Date / j / / / G // By .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372