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?RIo) Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
n,
44Ninsdo I. Blued File PERMIT NO. is-�a3(
GolCity
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/7303" )i /d/,L �Tr 1 SE 55$7
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
O
(Naamme))R rray go z I' i Ve (Phone) to Cdto 6784
(Address) 30ry L
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) shiftiest MN 55379
(Address _ .; „ (City) (Zip Code)
(Contact Person) I 11 2 (Phone) 953 44.5 48'0S
APPLICANT SIGNATURE il . (! _ .OA . DATE gig-g) 13
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,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 ,UMBING PERMIT FEE $
The minimum surcharge for a
CATE SURCHARGE $ f '
fixed fee permit is$1.00 DTAL PERMIT FEE $ J.3
This Application Becomes Your Building Permit When Approved Paid q/�/� Receipt No. �1(p
7
Dates ) so B f
Buildine Official Date 1� ALL"
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372