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2..Gold City
CITY OF PRIOR LAKE PLUMBING PERMIT
4,40,000
I.Blue File PERMIT NO. j4 `�qq
Gold
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3 c'1 ,, & .g ernu* C` . tt,k.) RI <>_IN
LEGAL DESCRIPTION(office use only) ,
LOT '34LOCK ADDITION /JP�E`�'r//0069C1) PID a7Jr
/ I'll-0/ —O
OWNER n 1
(Name) Charl,rs u,s+ ru.C\. (Phone) GI 5a--1-14-1 - 5 30.a
(Address) me
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Address)952-445-4803 (City) (Zip Code)
(Contact Person) ` (Phone)
APPLICANT SIGNATURE --\&rAA.. . ` DATE Z"I 1-I 14
APPLICANT 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
FEE SCHEDULE
Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,New One&Two-Family $149._'0
Residential,Additions&Alterations $49.51)
Estimated Cost $it p 6,C.,4 Building Permit#
PLUMBING PERMIT FEE $ s•CSO
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ SeA SO
(Office Use Only) ,
This Application Becomes Your Building Permit When Approved 0 / Receipt Not i S2,3
Date :y
Building Official Date
I
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 /