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04 Rt0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO
2. Gold City NO. p / L
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS _ ZONING (office use)
«S � � ,�, ► v\ I �
l l 1 s CT
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ul i / I ( Phon e)q... ` L `7�" S
(Address) rn L
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850 Chestnut Blvd.
(Aopee, MN 55379 (City) (Zip Code)
(Contact Person) ,i0trn ' 95 .� 4;48115 (Phone)
r ) 1./149:41-2
APPLICANT SIGNA _ /I Al • • � . / / DATE l
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher t 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
The Minnesota Statutes § 326B.148 FEE SCHEDULE
"SURCHARGE" has been extended ,f job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
The minimum surcharge for a Residential, Additions & Alterations $49.50
"fixed fee" permit is $5.00 $ Building Pe . it #
A
PLUMBING PERMIT FEE $ dr f
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ idt
(Office Use Only) -
This Application Becomes Your Building Permit When Approved Paid Receipt No.
1
Building Official Date Date g 11111 By l
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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