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plti Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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`tf I. Blue File
2 Gold city PERMIT NO. // 75-6
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
14051-1 RvAi - c rs Sk- 1`i F
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) \Otv id U 3 b (Phone) ° 1 - '4 4 S'" 3 Lt 4 C
(Address) \ L}DSq R 1 -erS Si". NE
APPLICANT
(Name) 31- 1815874 (Phone) ` 32-- `I 4- 1 -1 8b 3
(Address) Appliance Connections Inc
1 131aSikapita Circle (City) (Zip Code)
Shakopee, MN 55379 —
(Contact Person) 1 .TYl te, R ► P (Phone) `152 - y�15- U Xo 3
APPLICANT SIGNATURE c GI e, (Q-PpQP DATE 9 - 1- J
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher j 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 Thst $ Building Permit #
"SURCHARGE" has been extended OL U i t1 E
until June 30, 2013, PLUMBING PERMIT FEE $ STATE S URCHARGE $ � g , v C -51-1-6 _ 0 � � CZ
minimum surcharge for a v �� 5
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ S . 0 0
This Application Becomes Your Building Permit When Approved Paid , / o O Rece1pt No. 6 04
Date � `� � J (1 By/ /
Building Official Date I • / �-
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372