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4 PR/04, Date Rec'd
4:0CITY OF PRIOR LAKE PLUMBING PERMIT
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� oo .Blue File PERMIT NO.
.Yell App ///7�
3.Yellow Applicant 4�
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I5(a3Z I11 ; lc/AA Cir 56 he 6
LEGAL DESCRIPTION(office use only)
LOT ( BLOCK ADDITION in 1 l�&(-2 .PAci PID Z6. 155, o /. 0
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OWNER [� �f� /��7n
(Name) A i, .4 i ' SPA . ! Ls f (Phone) gJ —7TH;�/`1'
(Address) S 001—e-
APPLICANT
(Name) Appliance Connections Inc. (Phone) _
(Address) 12850 Chestnut Blvd.
iak�opar :, y 55379
(A a -445-480 (City) (Zip Code)
,
(Contact Person) I, AA R
,,-445-480
.1 0 (Phone) _
APPLICANT SIGNATURE I Ma rill 1/11/W/ DATE9(1 Ct z I -7 _
'PLICANT PLEASE COMPLETE BELOW
Quantity T t • of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher I 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 $ Building Permit#
The minimum surcharge for a
"fixed fee"permit is$5.00 PLUMBING PERMIT FEE $ ,1i
STATE SURCHARGE $ / . i
TOTAL PERMIT FEE $ s atiff.
(Office Use Only) , •
This Application Becomes Your Building Permit When Approved *d ..). ,<0 Receipt No. /,,.
Dat By 6
Bniidina Official - Date �-' (q t :2
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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