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Date Rec'd
04 P RI°
CITY OF PRIOR LAKE PLUMBING PERMIT
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41 vivESO ° 1. Gol Blue File PERMIT NO . ,076 2. Gold City %
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER - / �
(Name) 4I 1 i t. go • 4 (Phone) 0 I
(Address) J Lt 3/ G ; } S 9 ft
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850 Chestnut Blvd. (Zip Code)
(Aigopee, MN 55379 (City) ( p
., 2445-113
(Contact Person) ,' AA ' ■0 ' (Phone)
APPLICANT SIGNATURE ! M.4 !. !!I# DATE / AO 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
1 Dishwasher 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 $1 ' 0
Residential, Additions & Alterations 49:50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148 .
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ - - 0 f
The minimum surcharge for a TOTAL PERMIT FEE $ ----61#459—,
"fixed fee" permit is $5.00
_ .,, necomes Y our Building Permit When Approved Paid
,..4
..4 --1 / Receipt No • f
Date 3/7//1/43 B
Building 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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