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I CITY OF PRIOR LAKE PLUMBING PERMIT Y` /, j
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I. Blue File PERMIT NO. 7. -d�3 ,
2. Gold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
j //a3 C Cv NC Pw
LEGAL DESCRIPTION (office use only)
LOT i( BLOCK 2- ADDITION S/.1A)b &tie__ 3 A 3 bAl PID =,,M 00V-0
OWNER • I
(Name) A Al /il ' _ 1 l�; (Phone) � 1�� - — f 1l
(Address) i,,,ilt.z..,
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Sh t oiNc, MN 55379
5s ' 803 (City) (Zip Code)
(Contact Person _ , • ` / .6.1 -WI I (Phone)
APPLICANT SIGNATURE 1 ' MP DATE -7 36 .
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 $ 4(. r -v
STATE SURCHARGE $ .t-J ) '- '757
TOTAL PERMIT FEE $ ,,
(Office Use only) .,5Z
This Application Becomes Your Building Perm t W n Approved "a 1 Receipt No.
Date •
ad
D. e, By Anil
Buildfn e � ci a
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372