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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
Nl
'•P�s0.0 I. Blue File PERMIT NO.
2.Gold City I i
3 Yellow Applicant
(Please type or print and sign at bottom) ZONING(office use)
ADDRESS
3LJpp Spri GlcA R.
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(NameOWNER) \ t ' 0 d coni .....
`h �..2.5' 1-1-1/
(Address) /4o\p S X m LA-c",c' `, 0,ik
APPLICANT Appliance Connections !:lc.
(Name) 12R50 Chestnut Blvd. (Phone)
Shakopee, MN 55379
(Address) 952-445 1803
(Address) (City) (Zip Code)
(Contact Person) ...We' l i l _ (Phone) lit
APPLICANT SIGNATURE PP , .&i' ' / DATE
]LICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher % 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 Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 64.SO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 51/ 573 Receipt No. 7/L �/7
Date ` BY/ �
Buildine Official
Date ,7/�G�/ /
I
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372