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PRI) Date Rec'd
s CITY OF PRIOR LAKE PLUMBING PERMIT
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I.GoBluCit PERMIT NO.
2.Gold City (,� /
3.Yellow Applicant �/ • ` A�
(Please type or print and sign at bottom)
ADDRESS ZONING us=use)
(v05sk i( Dr, CZ
LEGAL DESCRIPTION(office use only) /1 //
LOT to BLOC& ADDITIONC 2;(e hhW 3400/0-•'-til j0 PID�Jc 3/1
OWNER 11 I 4,5V? 7r0—`04
(Name) kik r'/ ■ (Phone)
e✓
(Address) �! J)e
APPLICANT Appliance CJ.'°aectionslnc.
(Name) 12850 Chestnut Blvd. (Phone)
Shakopee, MN :1:1379
(Address) 9524-.'• 4%303
(Address) - / (City) (Zip Code)
(Contact Person). /04 i 1 / - � (Phone)
/
APPLICANT SIGNATURE _ DATE 1,2 b rI
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 $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended $ Building Permit#
The minimum surcharge for a
"fixed fee"permit is$5.00 STAMBING PERMIT et)
TE SSURCHARGEFEE $$
• TOTAL PERMIT FEE $
(Office Use Only) W
This Application Becomes Your Building Permit When Approved Receipt No. 6Vl
larIMILI ByBuildine Official Date 4.)
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372