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N CITY OF PRIOR LAKE PLUMBING PERMIT l , 17. 1 c
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��d � �B'"` F'e PERMIT NO. /4/. -1-0.1
.Yell Airy / �
S-Yellow Applicant / •
(Please type or print and sign at bottom)
ADDRESS /. ZONING(..office use)
) 1161 r 3rl� ?t5I WP1 15 �)
LEGAL DESCRIPTION(office use only)
LOT LOCK f ADDITION a- 1 If/to 'f Al l ir$ /C1/Y31 /475 4/-00:-A - D
O((NWNER /� ' l A ( V &fr (Phone) q50?'aJ1- -S.-13
L
(Address) 5 j t in Q/
APPLICANT
(Name) appliance Connections InC. (Phone)
(Address) 12$50 C!�e�•tni.lt �3 9
( •:r •-445-4'$U (City) (Zip Code)
74i
(Contact Person)i • , Fl4
(Phone)
APPLICANT SIGNATURE I a:A.ai! ./ DATE )( l f./20/
APPLICANT PLEASE COMPLETE BELOW
Quantity Type 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
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.148 it $ Building Permit#
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ / 15)
The minimum surcharge for a STATE SURCHARGE $ aiiitill i
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ • A
•
This Application Becomes Your Building Permit When Approved ;`f , Receipt No. 9� -
Buildin¢Official - Date iii
- ��i By 4-
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372