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PRION Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT /
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1.Bold FCit PERMIT NO.IL/' ,9,
2.Gold City _j
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS514 �� pini- C(• s �/ ZONINGA(office use)
FroLEGAL DESCRIPTION(office use )` ..Z
T G i - o�!�• c�O�J
LOT BLOCK ADDITION PID c v o
(NaWNER a I + / Ste. (Phone) 012- t9/°. )1910
)
(Address) 51-019 FlaSt P4�v t,1 C,i
APPLICANT Appliance Connections Inc.
(Name) 12850 Chestnut Blvd. (Phone)
(Address) Shakopee, MN 55379
(Addre` -445-4803 (City) (Zip Code)
(Contact Person) �� v R I . (Phone)
APPLICANT SIGNATURE • /t s A DATE 9
/ EL
A PLICANT PLEASE COMPLETE BELOW
O
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
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
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 51(,5-0
(Office Use Only)
This Application Becomes Your Building Permit When Approved c',4 '- 5D Receipt No.1 I�b
)ate f By
Buildine Official Date �'� `* 6iki-o(/24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372