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a Y RIO ' Date Rec'd
IP CITY OF PRIOR LAKE PLU 1 - T lig i . 1 I 11—
�INNESD
1 2 . Gol. Blue d F i l e PERMIT NO /Z--1 1
3. Yellow Applicant
(Please type or print and sign at bottom)
AD ZONING (office use)
1Th
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �.
(Name) rn' LA r I (Phone) g_ /A t)
..�
(Address) `2)1 I I .
APPLICANT Appliance Connections Inc
(Name) 1313 Da n i to Cr (Phone)
(Address) Shakopee, MN 55379
(Addr52 , 54003 (City) (Zip Code)
(Contact Person _,k (Phone)
APPLICANT SIGNATU • ,.30 . _ /` _ DATE (91/o o /,)( ,
APPLICANT 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
host $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ / s
The minimum surcharge for a TOTAL PERMIT FEE $ TO "fixed fee" permit is $5.00 . „ �'
This Application Becomes Your Building Permit When Approved Paid / S�
Buildine Official Date Re• - � No. /_ 7 r
Date 4 - 7- 1 Z (� J/ •
°'
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
IP .
4646 Dakota Street S.E., Prior Lake, Minnesota 55372