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VRI0� C/ Date Rec'd
a CITY OF PRIOR LAKE PLUMBING PERMIT 3 —
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I. Blue File PERMIT NO . /�� 5 4
2 3 .
Gold App � . /'�(
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 5" ()[V� /) d�r
OWNER ,
(Name) LA/ (Phone) q5-
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(Address)
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APPLICANT
(Name) Appliance Connections Inc. (Phone)
(Address) 12850 Chestnut Blvd.
(A opee, MN 55379 (City) (Zip Code)
52 '' 4803 j
(Contact Person) J I A .'e/ k ' I (Phone)
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APPLICANT SIGNATURE / II /A i & /. , / DATE ' r .- 4ti
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
ost $ Building Permit #
The Minnesota Statutes §326B.148 .—mi)
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ v
until June 30, 2013, STATE SURCHARGE $ -
The minimum surcharge for a TOTAL PERMIT FEE $ ____9fqa
"fixed fee' permit is $5.00
This Application Becomes Your Building Permit When Approved Pa' / 4 �� Receipt No. l J if
Buildine Official Date a / � 3 By ..:',„L__5,....._._-----
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372