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2. cola City CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue i PERMIT NO. 3 _ a `s '
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
51) 03 , Oak r \i-f- Pr,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER n �r ] (� (�(� /�
(Name) V s . n 71.0d ,f 19111 � E/I Std ✓I (Phone) �l5" j ` � ^ �f` — 7
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(Address) S a
APPLICANT Appliance Connections Inc.
(Name) 11850 Chestnut Blvd. (Phone)
(Address) Shakopee, MN 55379
(Add - 445 -48°3 (City) (Zip Code)
(Contact Person)--___i0 Mit gA prt_.-C- _ (Phone)
APPLICANT SIGNATURE 'Yh, L.; r2 DATE / db i
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher j 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 $ Lir Building Permit #
PLUMBING PERMIT FEE $ 1
STATE SURCHARGE $
TOTAL PERMIT FEE $ G so
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid' J / Receipt No. v
4/ By
Building Official Date Date
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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