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on) Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
440,000
I.GoldBlud File 24.
z. PERMIT NO. /5. /7
city
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I (.°361 OThb Cv 56
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OVVINI
((Name 4 ( S h (�Q ' 1/`i^ (Phone) (PI0 -30C-0187
C4
(Address) 5,,,,,,,
APPLICANT
(Name) liance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Chakopee, MN 55379
(Adder-445-4803 (City) (Zip Code)
(Contact Person) A _ (Phone) �,` �_
APPLICANT SIGNATURE Ji ; t ' DATE ' 117 d...61--
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
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
Estimated Cost $ Building Permit# The Minnesota statutes g SZbti.14ti
PLUMBING PERMIT FEE $ V "SURCHARGE"has been extended
_ The minimum surcharge for a
STATE SURCHARGE $ A_ "fixed fee"permit is$5.00
TOTAL PERMIT FEE $ �� / �;
( Office Use Only)
..,
�� ill
This Application Becomes Your Building Permit When Approved Paid 5, Fic eipt No.
Building Official Date DateV, t .
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372