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Pao Date Rec'd
,
i -y
e CITY OF PRIOR LAKE PLUMBING PERMIT
V ti
(Please . Blur F I PERMIT NO. I Z , 1 I I
4,:oviasoo
2. G old C it y
3. Yellow Applicant
(P type or print and sign at bottom)
ADDRESS
ZONING (office use)
? LI Sl mp 1< Dr:
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER nn
(Name) c00�nn I pek (Phone) 4 15A- 440 - 1 1030
(Address) 3%141' Si r n pK I n S Dr .
APPLICANT
(Name) Appliance Inatr dare et MN, Inc. (Phone) C152. -'w- 83
14105 Rutgers St. NE
(Address) Prior Witygrhss N 55372
(City) (Zip Code)
(Contact Person) M u t Ma min (Phone)
APPLICANT SIGNATURE DATE _2h
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of
Bath Tub with or without shower
Dishwasher Water Heater
Floor Drain l Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink
Shower Stall Assembl
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 $ 3268.148 Est $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
.Duly 1, 2010, until June 30, 2011. STATE SURCHARGE
The minimum surcharge fora "fixed fee" permit $ .50
is 5.5, beginning July' 1, 2010 TOTAL PERMIT FEE $ !'!„) f •$,:, 5 , SO
This Application Becomes Your Building Permit When Approved Paid 6---y JR R ece No.
Date -7 B
Building Official Date C , Z 1 Z-
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372