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PRI Date Rec'd
N 4 e CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO . J_3 /
2. Gold City • Z GGL
3. Yellow Applicant O
(Please type or print and sign at bottom)
ADDRESS n 1 i / \ ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER /5
(Name) 1 � ( (1 P-7-- 0 i t V (Phone) 6 15;i — '/ - q 057
(Address) 5eiriv—}
APPLICANT
(Name) (Phone)
Connections Inc.
(Address) 12111
C 1 flt�t Blvd.
J t (.` iMN i (City) (Zip Code)
(Contact Person)_ ' . f _ . , (Phone)
APPLICANT SIGNATURE 0.4 i.. _1_ / /. / DATE 46:1,2L3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 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
st $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ ,
until June 30, 2013, STATE SURCHARGE $
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 r• . ''�
This Application Becomes Your Building Permit When Approved Paid / Receipt No.
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Date ; / 9 f3 By
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13 uiliins Official Date Y
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24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 1
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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C084-aa.-981141.141