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Date Rec'd
(I RIO R
CITY OF PRIOR LAKE PLUMBING PERMIT
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A 'JNNES O �� 1. slt,e F PERMIT NO. I ' I .Z 47
3 . Yell A pplicant ■ p
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I q ( $ tALbira -r1 SIC '
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ?"C/ r (Cit L (. I b (Phone) q5
,d 3 - r / j
(Address) 1 4 q 3 131 1 (.Q, rb11' d
APPLICANT
(Name) 31- 1815874 (Phone)
(Address) Appliance Connections Inc
13l3Danita Circle (City) , (Zip Code)
(Contact Person) Shakopee, 65379 (Phone) 05g / f q.�' ` / ' Q 3
APPLICANT SIGNAT '. _ DATE r2A (96 / I
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
ost $ 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 $
This Application Becomes Your Building Permit When Approved Paid R pt No/
94- C V
Date
Buildine Official Date ( k
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372