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� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File pERMIT NO �
2. Gold City "'�'
� 3. Yellow Applicant
lease e or rint and si at bottom
ADD SS ZONING (ot�ice u�e)
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LEGAL DESCRIPTION (office use only}
LOT BLOCK ADDITION PID
OWNER c •
(Name) (Phone)
(Address)
APPLICANT Appifsnce Cnnnectlans Inc
(Name) ' (Phone)
(Address) .� ha�CO�, MN 55379
(Addr�!Z �O� (City) (Zip Code)
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(Contact Person (Phone)
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APPLICANT SIGNATU DATE
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture Quanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimuxn Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
�ost $ Building Pe 't #
The Minnesota Statutes § 32bB.148
"SURCHARGE" has been extended pLUMBING PERMIT FEE $
until june 30, 2013, STATE SURCHARGE $
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid� ,� Re i No.
Date,����� /2
Buildine Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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