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01 PRI% Date Rec'd
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CITY OF PRIOR LAKE PLUMBING PERMIT
1. . cod File
PERMIT NO. _
3. Yellow Applicant / z /� i/ V
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 511 p J Pa, NW
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION pID
OWNER q
(Name) MA C C CC) I' (Phone) 15 2 till 0- 2 1
(Address) 51 10 J.J"F ",' s Pa N
APPLICANT
(Name) Appliance Connections Inc. (Phone)
(Address) 12850 Chestnut Blvd.
SIB 952-445- MN bbi /y (City) (Zip Code)
(Contact Person) Tatittati3H (Phone)
APPLICANT SIGNATURE rib �., ' ' DATE ZIP
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
The Minnesota Statutes § 326B.148 Residential, Additions & Alterations $49.50
"SURCHARGE" has been extended st $ Building Permit #
The minimum surcharge for a
"fixed fee" permit is $5.00 PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5 • � o
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid iy) Receipt No. ,/ �f-
p'
Date 12 ) 4 . / By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
. .