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F CITY OF PRIOR LAKE PLUMBING PERMIT 4 /40 ,i2
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2. Gold City PERMIT NO. / _ 081/ `L
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 7BLOCK / ADDITION Alebedoax A3 r/ N PID 07;~.2(0; O& 7- o
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(Na R • t II III (Phone) tad '020
(Address) 5 V_ /
APPLICANT
(Name) Appliance Connections Inc. (Phone)
(Address) 12850 Chestnut Blvd.
;,,i... ` -, MN 55379 (City) (Zip Code)
'-4 -4803
(Contact Person `i AA a &e... (Phone)
APPLICANT SIGNATU' 0 DATE • _O 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 f Water Softener
Lavatory (Bathroom Sinks 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 § 326B.148 ;t $ Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ 0 J V
until June 30, 2013, STATE SURCHARGE $ ` a '16
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00 ,66 (G ( 0
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This Application Becomes Your Building Permit } Wh ^ en pproved • i d �� Receipt No. /'_ 7g
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Bu Official Date t i lve 1 B y ck
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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