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A. CITY OF PRIOR LAKE PLUMBING PERMIT
r,3 g /Oi / O, I 1-/
4,' e `. BI°° pile PERMIT NO. iV632.Yell pp 1I
3.Yellow Applicant ( '� I
(Please type or print and sign at bottom)
ADDRESS ..-'-. ZONING(office use)
i1 -i 1 iawks P ,p5 R2 S6
LEGAL DESCRIPTION(o use only)
LOT BL 'CK--6`ADDIT PID ,F5-43-(1/40-e2
OWNER
(Name) jw, Pcn4e vStj)1 (Phone) l-'� v 2)-5
(Address) 51 I ' 1 e,
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Ad -445-48 (City) (Zip Code)
(Contact Person).ja,YYI I i er (Phone)
APPLICANT SIGNATURE L�' . (Arid
DATE /2/ 2ô/
APPLICANT PLEASE COMPLETE BELOW / / Y
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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
Potimat d Cnct $ Building Permit#
The Minnesota Statutes§326B.148 PLUMBING PERMIT FEE $ . 1
"SURCHARGE"has been extended STATE SURCHARGE $ ...0-.00 p0 .S8
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee"permit is$5.00 —,,'
This Application Becomes Your Building Permit When Approved �, d , Receipt No. RI
Building Official Date ,MnnBy /
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372