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04 PRip Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO. / 3 ._ay
2. bold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 / (9 MULS krfbWil TOI
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION HD
OWNE I �,, (),5;?�p n j��/J /
(Name) pru ( I f�l le.�Y (Phone) — C — Z "' l 7
(Address) ,(,-
APPLICANT l "
(Name) App Connections Inc. t h on
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Addres3t2 -445 -4803 • r' (City) (Zip Code)
(Contact Person) N. ./I r� ie /, `/ (Phone)
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APPLICANT SIGNAT • _.-2.40 DATE 1 f;------7/ ? 1 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher t 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 LUMBING PERMIT FEE $ .4 ,
until June 30, 2013, TATE SURCHARGE $ �'W_ ,
The minimum surcharge for a OTAL PERMIT FEE $ s...
"fixed fee" permit is $5.00 ^ar
11 u1J LwFJIICd l/11 DCCUl11Cl z our Bunning Permit When Approved Paid Receipt No. f 7 ` ,31
Date / /� � ,(j By —tr /1'L=IIII
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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