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CITY OF PRIOR LAKE PLUMBING PERMIT
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?. col I. Blu d F ile I PERMIT NO. l
Cit 3 _1/4
3. Yellow Applicant
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS � + � 3tdl b u' er C' t N �(�I
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ,m 1I (Phone) 1 — (. 1q3 Lt.
(Name) NC i 11
(Address) 3 1 al p4e,r n Ct
APPLICANT (Phone)
(Name) Appliance Connections Inc.
12850 Chestnut Blvd.
(Address) (Ad - 445 -4803 Shi MN 55379 (City) (Zip Code)
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(Contact Person) �]t(l�'tJ� 4 (Phone)
APPLICANT SIGNATURE , i . 1 r DATE 5 ! 7
PPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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
t $ 9-1, b�V Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ 50
The minimum surcharge for a TOTAL PERMIT FEE $ �'�• 57) "fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid J - 4 . 5-� Receipt No. 9e 1 �—
Date 3 1 2 / BY i .4_,e_
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