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CITY OF PRIOR LAKE PLUMBING PERMIT
v
4,01Y.se ,.Gold
File PERMIT NO. 3(Z
2.Yell App /�`
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESSZONING(office use)
Yo 93 Coa iii L-ane---
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Nam) 0.et (U l ( QL (KvIL kLl' (Phone)
(Address) S at..,
APPLICANT
(Name) (Phone)
Affiance Connections inc.
(Address) 12850 Chestnut Blvd.
S appae, MN 55379 (City) (Zip Code)
952-445-4803
(Contact Person) f i (Phone)
APPLICANT SIGNATURE I11,,_ . i /A,/ DATE I h i,
.1-
A
APPLIC• 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 " Building Permit#
"SURCHARGE"has been extended /
The minimum surcharge for a :,UMBING PERMIT FEE $ _
"fixed fee"permit is$5.00 CATE SURCHARGE $ ---
OTAL PERMIT FEE $ . . dr
This Application Becomes Your Building Permit When Approved Paid 94V ceipt No.t trii,,..
Date it, 'c \
Building Official Date `'T i
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372