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?R1 1 Date Rec'd
t~ CITY OF PRIOR LAKE PLUMBING PERMIT j/ /2 - (3
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4 NESO 1.3
' oe Bile P ERMIT NO
2. Gold City . J ' J !"
1 Yellow Applicant
lease type or print and sign at bottom)
F _T
ADDRESS ZONING (office use)
38/42. 6 p ns l- 5c.v P a2)
LEGAL DESCRIPTION (office use only)
LOT 3 BLOCK 3 ADDITION / - 1A 1 /U 4 G.„,c�TNfJ „, - ` 4.5- PIDo? g qg — G //,-- e
OWNER n y.{_, •
(Name) G 1 L°.O X ) r °L 1 11 445 (Phone) Q r. - Litil - a't tv6a
(Address) gyp,
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Adc445 - 4803 (City) (Zip Code)
(Contact Person), f (Phone)
APPLICANT SIGNATURE .s.J�''n ;42, _egg DATE l9/ !
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
The Minnesota Statutes § 326B.148 Residential, Additions & Alterations $49.50
"SURCHARGE" has been extended st $ Building Permit #
The minimum surcharge for a
"fixed fee" permit is $5.00 PLUMBING PERMIT FEE $ 6 OO
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5'/ 6
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid As 2 / / Receipt No. di g
Building Official Date Date ///7/ Bydr —
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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