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4 R/04. Goo /, 1 Date Rec'd
a te CITY OF PRIOR LAKE PLUMBING PERMIT
INNESD�
I. File PERMIT NO. /�
2. Gold City . p //7 t0.//
. / l
3. Yellow Applicant 1V/
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/ J 7 '9/ F4
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Qg-T / - o c e Pe !,
(Name) ( < (Phone) eV Syr S
(Address) S """--
APPLICANT
(Name) Appliance Connections Inc (Phone)
(Address) 1:31 a
S de t 5 . 4 .,.; . 7. (City) (Zip Code)
(Contact Person) 952445 -4803 (Phone)
APPLICANT SIGNATURE 4 Y /1 DATE '/ /
I ( (
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
Estimated Cost $ 2OV Building Permit #
PLUMBING PERMIT FEE $ y`7 =�
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5-6
(Office Use Only)
This Application Becomes Your Building Permit When Approved D t • :4, I Receipt � a� 1i111 No.
Pli 1 5 Znig 11'1 BY
Building Official Date
24 hour notice for all inspections (952) 1 i -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior L ,