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PRio Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
7.3 hi
A '�vES °� I. Blue File 0 ���
2. Gold City PERMIT NO. /3_
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (orrice use)
1 3(0S Ji 1 At I( noS.Ss Ki, .e, t"
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER '
(Name) _ , 1 di /1 ' a V1 (Phone) ft.. ' t -
(Address) 0 r\—C.'
APPLICANT
(Name) Applianc Cunnections Inc. (Phone)
(Address) 12850 Chestnut Blvd.
,utt MN 55379 (City) (Zip Code)
952 -4 4803 I vt (Contact Person) al( t - 1 / (Phone)
f`/
APPLICANT SIGNATURE iV / l DATE Y
IF
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 I% 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 $ Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ if :
until June 30, 2013, STATE SURCHARGE $ • 451
The minimum surcharge for a TOTAL PERMIT FEE $ ,
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid g J � Receipt No 9(
Date By
BuildiuE Official Date / %
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372