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(ji) Rfic Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City PERMIT NO. 6_ 3
.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 Co5"7 1 NorAwood ?oi NIA)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER G
(Name) t — Qrna r Pa rl (Phone) ( L
t7 � S
(Address) il / ' -
APPLICANT Appliance Connections Inc.
(Name) 12850 Chestnut Blvd. (Phone)
(Address) Shakopee, MN 55379
(AddrPs -445 -4803 (City) (Zip Code)
(Contact Person) i (Phone) ij/i /
APPLICANT SIGNATURE . #Ii1I ' g _ k
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
Lavato Bathroom Sink Stand Pi se (Washin• 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
t $ Building Permit #
The Minnesota Statutes § 326B.148 I ,
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ '/' L
until June 30, 2013, STATE SURCHARGE $ Ir „00 -31C
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee' permit is $5.00
This Application Becomes Your Building Permit When Approved Paid Recei.t ‘ ge B y -V.1-aa--,,t, 5 .-L--' 0,4Q7-6::
Aft
Buildin f is Date EMS= r
- 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372