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pRI Ci Date Rec'd
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CITY OF PRIOR LAKE PLUMBING PERMIT
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••rv85 ° �� I. Blue File pERMIT NO.
2. Gold City ) z — i // T 9
3. Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
a 4I Att. ! - 6
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Na /� ft" Q 1 L ( t �� (Phone) — (/✓
(Address)
APPLICANT
(Name) (Phone)
Appliance Conneciiuns Inc.
(Address) 12850 'Chestnut Blvd.
(• • 'y (City) (Zip Code)
(Contact Person i a/II 2> . , f0' V I (Phone)
APPLICANT SIGNATURE f DATE AIL04264..,),
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher C 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 UMBING PERMIT FEE $
until June 30, 2013, ATE SURCHARGE $ '"�ril?i .• -Sfr
The minimum surcharge for a )TAL PERMIT FEE $ r •
"fixed fee" permit is $5.00
1 uusa .tappm.stuVL iscuttittva i Vu! Du11u.,ig Permit When Approved Paid Receipt No. 7727
Buildine Official Date Date 42_ ` Z // By
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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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