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0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
SO t. sme Fite NO. `
2. Gotd C ity
[PERMIT /� / z/
3. Yellow Applicant �J
ease or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) _ I 4 Y • (Phone) - 33 ' 0 3l0CP 4. ame) i .
(Address) M &
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Addrre$ /, 45 -4803 , (City) (Zip Code)
(Contact Person .4i. f ii , lam/ 1\� . / O ' . (Phone)
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APPLICANT SIGNATUREIIIM l 4 to Agf / DATE 3
Or
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
The Minnesota Statutes §326B.148 of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
"SURCHARGE" has been extended Residential, Additions & Alterations $49.50
The minimum surcharge for a ;t $ Building Permit #
"fixed fee" permit is $5.00
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .56 5 V
TOTAL PERMIT FEE $ _____94
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid si j3 -- 0 Receipt No. 70 1
Building Official Date Date / 1 / / / By �,
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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