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t CITY OF PRIOR LAKE PLUMBING PERMIT
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Blue File
2. cola city PERMIT NO. /2 _ 76
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
---'15- N[
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) . \ d 5 (Phone) 0 15, (MS' (Ay
(Address) Ste- ouja msu
APPLICANT Appliance Connections Inc
(Name) 1313 Danita Cr (Phone)
(Address) Shakopee, MN 55379
(Address) 952 - 44548 3 (City) (Zip Code)
(Contact Person) 6 .11tf/4 (Phone)
APPLICANT SIGNATURE %1/,t , . ' / �: s DATE �
1 L
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
The Minnesota Statutes § 326B.148 st $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ �.5
The minimum surcharge for a STATE SURCHARGE
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ -
This Application Becomes Your Building Permit When Approved Paid , / Receipt Not 3 16
Date 74 � / � By Ip �
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
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