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4 Pgr04 Lam
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
/or ` /y
$00 I.Blue File
2.Gold City PERMIT NO.
pC De
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING!office use)
1-102 9 1 Q OCItJer 1.(- I /64t1 ,
LEGAL DESCRIPTION(office us,only)
/�/� YUiN(trc �F A�
/2. �LOT BSC�CK � TO / PID,,15-05Z—016-
OWNER `
(Name) .S - 77 7--.3)a 7
AO , � /. /, � J, (Phone)� p?
(Address) 54 Y1(1 a
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chesil!it Blvd.
(Address) Shakopee, MN 55379
1 (Addy ` 445-4803 (City) (Zip Code)
(Contact Person) AA I h► (4V ' (Phone)
f �APPLICANT SIGNATURE ' i Ai.� �.... II/ DATE CI. I°I, i LI
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 C.ommPri iol a�..i+:-f--t->>%of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
The Minnesota Statutes§326B.148 Residential,Additions&Alterations $49.50
"SURCHARGE"has been extended
The minimum surcharge for a 3st $ Building Permit#
"fixed fee"permit is$5.00 PLUMBING PERMIT FEE $
STATE SURCHARGE $ Q( etr
TOTAL PERMIT FEE $ _��
.
(Office Use Only) �
This Application Becomes Your Building Permit When Approved I,�; i en OW # Receipt No. / / it
mi
ate (•
V I By
Bandit's Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372