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CITY OF PRIOR LAKE PLUMBING PERMIT - /z��13
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I. Blue
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2. G PERMIT NO . 1 3_ 02 ,33
Gold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS fr 1 ZONING (office use)
1 ed'im ) � i) R 1S-b
LEGAL DESCRIPTION (office use only)
3 'i IO /
LOT 1 BLOCK 3 ADDITION ] /4-KM V i,1,t) 5 — PID 5:(5,21.- 01/
OWNER (Phone) 60 / / �+ s z! u
(Name) ----- r A
(Address) 60 rnU
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850 Chestnut Blvd.
(AdShaj(Opee, MN 553(9 (City) (Zip Code)
952 - 445 -4803
(Contact Person) (Phone)
APPLICANT SIGNATU' a JUL, [ . DATE
I '�
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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 I% 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 Est $ Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ ilq, 51)
until June 30, 2013, STATE SURCHARGE $ , no ,44a-
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ L
This Application Becomes Your Building Permit When Approved i& `C0 Receipt No. 6,g q 7
Building Official Date
Date._ > ` � By 5 /5„.........
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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