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04 RIp Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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,. Blue File NO. / / G
2. Gold City PERMIT NO /
3. Yellow Applicant r
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
WO 1 I (l y �, -�- cam E I�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER /
(Name) / . (Phone)
(Address) I( p' � 1 1,0 / 4-e
APPLICANT
(Name) (Phone)
Appliance Connections Inc
(Address) 1313 Dani *R Cr
(Ae opee, MN 55379 (City) (Zip Code)
(Contact Person) 952- 445 -4803 (Phone)
APPLICANT SIGNATURE JO/ fl Q, P 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
0 J
ost $,260 ° Building Permit #
The Minnesota Statutes §326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ q. 5
until June 30, 2013, STATE SURCHARGE $ 1 (.'N
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ _
This Application Becomes Your Building Permit When Approved Paid � , L S - 2 ) Rece t No./ / ii /
Date Q Z � _ By
Buildinu Official Date 7 •
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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