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4 V RIO Date Rec'd
. °� CITY OF PRIOR LAKE PLUMBING PERMIT FZ6,/3
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I. Gold File
2. cola city PERMIT NO. ( 3 , c3 4-
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
)13 � �- e d Dr, 72—
LEGAL DESCRIPTION (office use only) a , � LOT K.' BLOCI3 ADDITION e � ' 47t ,t � PID a5 g - 047- 0
OWNER �/
(Name) -L I4 ' ` V O 1 50 Y (Phone 95i-a3(p-5.5 - qc=1
(Address) g
APPLICANT
(Name) Appliance Connections Inc. (Phone) t12. �S ,7
(Address) 12850 Chestnut Blvd.
- 11 • -0 1. s•- : • • 1 • •
(City) (Zip Code)
, , , - -4803
(Contact Person) ' LI ►.i :.! _ $ (Phone)
• f`:
APPLICANT SIGNATURE :,'A... ,Ais gAt DATE 4/62.P )3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended s $ Building Permit #
The minimum surcharge for a ,/)�
"fixed fee" permit is $5.00 PLUMBING PERMIT FEE $ V
STATE SURCHARGE $ 6,. .00517'
TOTAL PERMIT FEE $
(Office Use Only) i O
This Applicati ec s Y r Building Permit When Approved 1 d ` _ O Receipt � - ��
. 2 G' 1� Date By
w' Mill Building Official Date
or
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
11
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