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04)Cm 4 P RIO Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
CV rsoi _
slue File PERMIT NO (
2 . Gold C ity ��' - L7,5
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
OWNER PL x l� r — v q (Phone) ) ' 740 i7 1
(Address) 1 53P 1A)1 1 d v e 3 � i IV v `i t f 7 U LGl.� 55372 -
q�,pliance Coon tions Inc.
APPLICANT 12850 Chestnut Bivd.
(Name)
Fi, MN 5537. (Phone)
Shako
(Address) 952 -4ee45 -4803
(Address) (City) (Zip Code)
A
(Contact Person) i')'\ ( (Phone)
APPLICANT SIGNATURE DATE 1 l 9 i .
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 0 Water Heater
Floor Drain a) 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
Estimated Cost $ ,/% . `2" Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ Sq.
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ sq .
"fixed fee" permit is $S.00
- .... tpimvatiuU De..u,nes 1 our remitting Permit When Approved Paid \.4 �-) Receipt No. a � 7/
Buildine Official Date Date � , By/ 4 r_ z -
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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