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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File PERMIT NO .
2. Geld A p p // / / /�
3. Yellow Applicant ` ( 6.
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
n205 Qe 4 ad
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ��
(Name) T 4 gA/
t S''1 LU- C CL. a (Phone) "5)- 2 JSc)
(Address) 11 be .G4- fi ci. . d P--c
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APPLICANT Appliance Connections Inc.
(Name) Fast Quality Installations (Phone)
Phone: 952- 445 -4803
(Address) Far: 952 -496 - 0064
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE ! EI.Gr DATE I i
ill — v
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 1 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 $ I49.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes $ 326.13.148 )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 $ 5
is; beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid S s � Receip . 6 ¢ ZZ.r
Date 1-- By
Building Official Date ` t!)
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372