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CITY OF PRIOR LAKE PLUMBING PERMIT c o5 4
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'��0/Eso�r .Gol File PERMIT NO. l '.Yell App /� TaT, ,S.Yellow Applicant -t
(Please type or print and sign at bottom)
ADDRESSZONING(office use)
c2 ( J Aare LaMt ' > '�
LEGAL DESCRIPTION(office use only) _ /
pm 2,..C: 215. 0
4,/,47�`� 4 its9 . 0
LOT�✓BLOCK ADDITION �ig/CJ�
(NaamNeOW )R AnCT. ic i m ba t LWI1 . (Phone)95d / O' LS
(Address) 4 Q-,•
APPLICANT
(Name) A p p I i a n c e Connections Inc, (Phone)
12850 CF 3estntat 1.9!vd.
(Address) Shakc,.: :::-.A 55379
(Addre02- 45-4803 (City) (Zip Code)
(Contact Person)j al l,N Q� {Y/ (Phone)
APPLICANT SIGNATURE - % i it DATE ib
APPLICANT PLEASE COMPLETE BELOW
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 ,
The Minnesota Statutes§326B.148 FEE SCHEDULE
"SURCHARGE"has been extended >f job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The minimum surcharge for a
"fixed fee"permit is$5.00 $ Building P- ..'
PLUMBING PERMIT FEE c°Si Allr-4
STATE SURCHARGE $ .�. .� ..
TOTAL PERMIT FEE $
(Office Use Only) a - 4
This Application Becomes Your Building Permit When Approved Ilio,id 11
Receipt No. w
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- By
Buildine Official Date l
Ao/0
24 hour notice for all inspections(952)447-9850,fa (952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372