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04 VR10 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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MNSSOo I. Blue File . Gold City PERMIT NO . 13
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
%533'7 ereezj Pb/ v i d SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � /
(Name) ( C /'ham. �'S l /.Cy7 (Phone)
(Address) 11 3 3 7 61 ee 2_1 l /n — /20 Pr ,&ci.Ke /eat Al 63' 37Q
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850 Chestnut Blvd.
(Addy akopee, MN 55379 (City) (Zip Code)
(Contact Person) 952 - 445 -4803 (Phone)
APPLICANT SIGNATURE DATE
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
The Minnesota Statutes § 326B.148 t $ Building Permit #
"SURCHARGE" has been extended
The minimum surcharge for a PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid d Receipt No. r 49/
c y
Buildine Official Date Date 9/ By
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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