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0 h CITY OF PRIOR LAKE PLUMBING PERMIT /0: /,e /3
I. Blue City File
2. Gotd City PERMIT NO. /3 /13A
3. Yellow Applicant
lease or print and sign at bottom)
ADDRES (office use)
Li*? , bt )v0d S F. St 8
LEGAL DESCRIPTION (office use only) t
# -r'r'' l✓,G - C. /G *4 3 $
LOT 4LOCK ADDITION PM 1 3 ,29 036-o
OWNER ,----- — ,9 in
(Name)._ ' A 1, r A, /../ (Phone)
(Address) Sat y
APPLICANT
(Name)_ Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) FO
��cco��ppce, MN 55379
9 21445 -4803 (City) (Zip Code)
(Contact Person) (Phone) /I
APPLICANT SIGNATURE AAa. , ' IMI° 4 1 DATE 1 3
APPLICANT PLEASE COMPLETE BELOW
• uantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher A 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 Building Permit #
"SURCHARGE" has been extended
The minimum surcharge for a UMBING PERMIT FEE $
ATE SURCHARGE $ A
"fixed fee" permit is $5.00 ITAL PERMIT FEE $
`S. y r
.5
This Application Becomes our Building Permit When Approved ` ' ;, d D Receipt No. 1
5 !� i O l • 13 ► ate‘ 0 . I< t 13 By 4 , _
Building Offic Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 - 4245 I
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
T.