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C .. Date Rec'd
04 r�o�
0 CITY OF PRIOR LAKE PLUMBING PERMIT
c vNEsoo N 1. Blue File
2. Gold City PERMIT NO. /L _ /305
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Vic{ i% S.pr� Rct c SW
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) U U'0..Q G i id l SICOV 511 (Phone) ' 2 - +/-0- 19 b
(Address) IA SPYI t L -661\-C- ' Rd dV
(Name)
APPLICANT 31- 1815874 (Phone) 1Q 4i d r
Appliance Connections Inc
(Address) 1313 Danita Circle
ShaketitierIVIN 55379 (City) (Zip Code)
(Contact Person) ,km,t&(i 4p f‹,t (Phone)
APPLICANT SIGNATURE ?S 1 A p9i4 DATE 0 - 3- — 2 --
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 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
" ' • ' ' "lst $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ fi} , 'CO
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid ay/ - Receipt No.i 7
Buildine Official Date Date /6 9 / L By 14 ,....,_.
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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