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4'PR 0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
INNES °o I. Blue File PERMIT NO .
2. Gold City /3 _ 1 6 9 U
3. Yellow Applicant O
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1S9-R 169-1-10 Dry cCry i S�
5
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER n ( Y ) ,, l2 (' 01 2-! 1 (Name) l � � (Phone) Y�
(Address) 1 0 m fD cl 7 S�
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850 Chestnut Rivd.
(Address) =' D02, . ",,, 55379 (City) (Zip Code)
(Contact Person) (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 compaitinent 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 l% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
J J Residential, Additions & Alterations $49.50
Estimated Cost $ ' `Q Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ L , L .50
TOTAL PERMIT FEE $ 9 .
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372