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CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Gold pile PERMIT NO. J
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS I ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( 0 1va WNER j �3 jf ` G h ( Phone ) q5,?-- `1 'PO- . >J 8e (Address) � A y-yt-t
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee MN 55379
(Address) 952 ' ' rTik
(City) (Zip Code)
(Contact Person ��i l j (Phone) J` APPLICANT SIGNATURE
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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 $ .
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ` �� Receipt No . , .
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Building Official Date Date �/ ,11 By /
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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