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�F P R I0 L, - Date Rec'd
;,.\,A CITY OF PRIOR LAKE PLUMBING PERMIT
NNE5O�
I. Blue File PERMIT NO . 09
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2. Gold City �
3. Yellow Applicant i 03
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 n
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER V a (Ai\ V40\e/ii (Phone) ` 1 • ..,-)1D+
(Address) I5 b) f Pass
APPLICANT
(Name) Appliance Connections Mime)
(Address) 1313 Danita Cr
(Address) Shakopee, MN 55379 (City) (Zip Code)
(Contact Person) 952-445-4803 (Phone)
APPLICANT SIGNATURE 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
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ SO 0 ()
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid (1,3 RecejrNo. 50 ` 7
Date 77
Building Official Date / d l !.- , 1
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372