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H CITY OF PRIOR LAKE PLUMBING PERMIT J / J 3
I. Blue File
2 PERMIT NO. 1 5 2. Gold City ..
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 il M CurS h St B 1 S-6
LEGAL DESCRIPTION (office use only)
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LOT 1 BLOCK P. ADDITION 7 L i ,v J i- j /' 4 _ Ai pID
OWNER
(Na M t, C M.L! Y 0 1 'I (Phone) /5 -2 - /q7- � 7 7
(Address) ** G . h 5t -
APPLICANT
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shaknpee, MN 55379
(Addre _445_4803 (City) (Zip Code)
(Contact Person) J a VY1 C & AP`P C 1 (Phone)
?"04pep APPLICANT SIGNATURE DATE :3- - 2:7 / 3
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 i 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
The Minnesota Statutes § 326B.148 St $ 3O nC Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ TV. SO
This Application Becomes Your Building Permit When Approved Pt it e t 5 Receipt No. 53 ,
V/4- ta
B Da By J
uildine al Date I ( .-
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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