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CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File
2. Gold City PERMIT NO. 4 _
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— ! � l �^ F'a IA?? ( � f � Gt. b h 15 ex ► pi (Phone) r (.� ! 6_ 71 b 1 0
(Address) 1
APPLICANT
(Name) (Name) (Phone)
Apples Connections Inc.
(Address) 12850 Chestnut Blvd.
Shakopee, MN 55379 (City) (Zip Code)
-445 - 803
(Contact Person A ` . ., a
,. (Phone)
APPLICANT SIGNATURE / iaii 4[ 1 :. , ',./ o ill 1 DATE j 2l
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ i'lq.5°
until June 30, 2013, STATE SURCHARGE $ x^Q sg-
The minimum surcharge for a ,, , b
TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 / .
1 uis Hppucauon Becomes Y our Building Permit When Approved Paid L--,/ �--- Receipt No. r p s (/
Date /, �, J By � _
Building Official Date ��Vj �� ,��
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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