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pi PRIpp Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
4rote
i. Blue File
PERMIT NO. 15 124_ _
2. Gold City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
111 AM 9Li rnrY4 C r )J k)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER(Name) ...11yV Aa 15/61/0-03
� % /2
1 ` (Phone) _.,g,
(Address) 590eNg.../
APPLICANT
(Name) Appliance Connections Inc.
12850 Chestnut Blvd. (Phone)
(Address) She ° - =: MN 55 79
A
NOF
(Address) (City) (Zip Code)
(Contact Person) _u.114,/1 (Phone)
APPLICANT SIGNA ' . ifflieW...- ...,,A,A5ffli / DATE
1 -Ii=2724-
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher , Water Heater
Floor DrainWater 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 )st $ Building Pe 't#
"SURCHARGE"has been extended /1)
The minimum surcharge for a PLUMBING PERMIT FEE $ �, "J "
"fixed fee"permit is$ .00 STATE SURCHARGE $ Min-,SAS..
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paidc5 Recei t No. Z6 0
Date By (�
Buildine Official Date a . ti.>s
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372