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04 p0� Date Rec'd
,� CITY OF PRIOR LAKE PLUMBING PERMIT
4 sdis
I. aiu< File
2. cow city / PERMIT NO. ./3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1- (13 S+ 5
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION MD
OWNER � A
(Name) �� 1n (Phone) _. ..! — • P ♦• " �/
(Address)�.)
APPLICANT In (Name) Appliance C1ect� lOfli (Phone)
12850
(Address) ee. Chestnut
(Addres
952 - 445 -4803 (City) (Zip Code)
(Contact Person) I • ( Phone)
l
APPLICANT SIGNATURE 1 • . ' I , A « DATE 0 / A I
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher k 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
The Minnesota Statutes § 326B.148 Residential, Additions & Alterations $49.50
"SURCHARGE" has been extended
The minimum surcharge for a $ Building Pe it #
"fixed fee" permit is $$. 'LUMBING PERMIT FEE $ v .6
;TATESURCHARGE $ h7 t
TOTAL PERMIT FEE $ - • •
(Office Use Only)
01/1 d
This Application Becomes Your Building Permit When Approved Paid / ` 3 - 0 Receipt No. 2
Bnildine Official Date Date / a /3 B 4 a
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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