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CITY OF PRIOR LAKE PLUMBING PERMIT
ar �'NES°
1. Blue File PER NO. /� / 9
2. Gold App �3 V (o J
/
7. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
A 1114
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER' r
(Name) o, U / Z& Y
(Phone) 17.3,- 4� ' /1/60
(Address) S q1 L/
(Name Appliance Connections Inc.
12850 Chestnut Blvd. (Phone)
(Address) Shakopee, MN 55379
(Add9N-445 03 (City) (Zip Code)
(Contact Person) . (Phone)
APPLICANT SIGNATUR /JAL . /`,' I DATE 1 1 .i Of I
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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ Ld
until June 30, 2013, STATE SURCHARGE $ °WI , . 1
The minimum surcharge for a TOTAL PERMIT FEE $ _4
"fixed fee" permit is $5.00
1 hias Application necu>t..cal i mu. „u...iing Permit When Approved Paid t -- Receipt No. 6 g 2
Date /.h / By i.,_ii,,I.:2;—
Buildine Official Date
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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