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o 1CITY OF PRIOR LAKE PLUMBING PERMIT
IA'NESds
I. Blvd File PERMIT NO . /
2. Ye App ii r I
3. Yellow Applicant (((
(Please type or print and sign at bottom)
ADDRESS � ZONING (office use)
S i vtb\c_S C►e- Sc
LEGAL DESCRIPTION (office use only)
•
LOT BLOCK ADDITION PID
OWNER \O _ 4 1 1 Ie c (Phone) C ✓(/1 1 4 � "i q: > " Address Amn C T'r � �
(Address) 5 1Z 'fro - .
APPLICANT
(Name) (Phone)
Appliance Connections Inc
(Address) 1313 Dania Cr
(Address) (City) (Zip Code)
Shakopee, MN 55379
(Contact Person) 95 8p3 (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher f 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
The Minnesota Statutes § 326R148 ost $ 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 $ ji 1
This Application Becomes Your Building Permit When Approved Paid riffb Recei No. / 44
Buildine Official Date Date � A l i By
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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