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4 PRi Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO. j
2. Gold City . p / I
3. Yellow Applicant !!! IIII
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 g J uin Sh ofe-s Try ' RI SI)
LEGAL DESCRIPTION (office use only)
l ° BL P, 9`r44�� ,
LOT BLOCK ADDITION PID 45 co 3/- co q--0
OWNER
(Name) c en mit (Phone) 4 L 10 61)-
(Address) 9451 1 iii aAA telt-_.S ill
APPLICANT
(Name) (Phone)
(Address) Appliance Connections Inc.
(Address) 12850 Chestnut Blvd. (City) (Zip Code)
Shakopee, MN 55379
(Contact Person) 952- 445 -48P (Phone)
APPLICANT SIGNATURE DATE 0441 S .
PPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower 0 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
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended Est $ Building Permit #
The minimum surcharge for a PLUMBING PERMIT FEE $
"fixed fee" permit is $5.00 STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 91, 51
._.
(Office Use Only)
This Application Becomes Your B ding Permit , W en Approved tk `c D Receipt No. to n g
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Building Oft'icia ' Date SIB
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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