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Date Rec'd
4.01 7Rro .
CITY OF PRIOR LAKE PLUMBING PERMIT . Is"7. 13. �
r4Ntvaso'� I.Blue File PERMIT NO.
2.Gold City /5 eg05"
3.Yellow Applicant ✓✓
(Please type or print and sign at bottom)
ADDRESS ZONING(orrice use)
11-12-1, SINbill 6f:4/ILI* R) s_h4
LEGAL DESCRIPTION(office use only)
LOT BLOCK / ADDITION TL",PI "s l PID Q5 R87- 69°a
OWaNER 72- O -=g, 1 v'( J`. -. (Phone) I ,�- ;7 v3 1
(Address)
APPLICANT Appliance tit ",n-ctions, Inc.
(Name) 12{30 C.l i ��tn t Blvd (Phone)
(Address) Shakopee, 4� 4 55379
(Address) 9b2-44:i-4803 (City) (Zip Code)
(Contact Person) 7)-130\A ( - (Phone)
APPLICANT SIGNATURE ,fL.I .w tri DATE '714_5"
•
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 400 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§32613148 Job' SCHEDULE
cost with a$49
FEE.50 minimum Residential,New One&Two-Family $149.50
"S1IRCHARGE"has beep extendeda Residential,Additions&Alterations $49.50
The nlininlum surcharge for
$ Building Permit#
"fixed fee"permit is$5.00
PLUMBING PERMIT FEE $ 91-s D
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved 4p4 ,go Receipt No.-7 0
Date 1/. 13 ,s By C
Buildine Official Date l J
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372