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CNES) Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
I. Glue File PERMIT NO . j am'
2. Yell Airy /Z - /� . J
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) OWNER �0 S o f ehrovirri-retw, (Phone) 459 bi
(Address) ('-` _ A nil'
APPLICANT Applian Connections Inc ‘y
12850 Chestnut Blvd. ` done)
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(Address) Shakopee, MN 55379 '1 /
(Address ,52-�445-4803 - V ' (City) (Zip Code)
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(Contact Person) o iv gi (Ph one) G _ - `T "( 1 y,�
APPLICANT SIGNATURE _ _AA . , -ic. DATE �� ` I 1 I ?x/ ..
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 6 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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ at
until June 30, 2013, STATE SURCHARGE $ , A f�
The minimum surcharge for a TOTAL PERMIT FEE $ / /
"fixed fee" permit is $5.00 ` '
1 n15 Pi p p,n;ai)II DCCUILICS 1 out building Permit When Approved Paid .3-4.5-0 Receipt No. . i
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Building Official Date Date / , / / 7/ ! 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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