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CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Glue File PERMIT NO . t
2. Gold iry l / 2_, _ f �
3. Yellow Applicant
(Please type or print and sign at bottom)
ADD SS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) fly la �./ 1 (Phone) � - `� 00 ' fr 5
(Address) 5 o t...
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Addre2- 445 -4803 (City) (Zip Code)
(Contact Pers s . A . AA • a , 1 ' (Phone)
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APPLICANT SIGNATURE : _ >4ak.. _Iglu DATE / ?V MAIO
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ ' 20 ..5t'
TOTAL PERMIT FEE $ *e,
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Z-. % 5 Receipt No. /
Building Official Date Date f J 4 ' $y '1 /!
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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