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O 4 V Rio Date Rec'd
5, CITY OF PRIOR LAKE PLUMBING PERMIT
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2. Ye t PERMIT NO
Yellow App NO. j3 _� T L.L
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
61 Wdto( 40rse, PISS
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
ER 13 1>W1 �-L �' �/
(NaOWNme) � (Phone) � � � ' � �C 0 30
(Address) ''J E I WM 4o Pa.cs
APPLICANT Appliance Connections Inc.
(Name) 12850 Chestnut Blvd. (Phone)
(Address) Shakopee, MN 55379
(AS152s45 -4803 (City) (Zip Code)
(Contact Person) T &t v RA c)
P (Phone)
APPLICANT SIGNATURE -
4 4 i i v a k- 1 ° / DATE ei r "
3
AP ' LICANT 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 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
00 Residential, Additions & Alterations $49.50
t $ ?O0. W 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 $ Lfq, 67) s c 31
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid Z.9 Receipt No., l j
Date // By c),.i-r•
Building Official 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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