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04 pRI0� Date Rec'd
CITY'OF PRIOR LAKE PLUMBING PERMIT .
LNES) -
1.fted File PERMIT NO /f it/7g
YellowelCity / �F / 7�
3. Applicant • �
(Please type or print and sign at bottom) - w
ADDRESS ZONING(office use)
g43aO Lala ,4-V fes& - 553-7 R &VS:6
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION �0 12�4.1/90,61 .6 A vorki PID Lc— / c:;) `CO - 0
OWN(Name)R 6( i'C:f/ ar a. dro5 /Q a (Phone) b/ -C9X 4 78-8'
(Address) ` 3 0 i1'L ?
APPLICANT ,
(Name) Appliance Connections °ne)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379 Zi Code)
(Address) f 952-445-4803 (City) gip
(Contact Person) --1044 le et •ro.,1 (Phone)
APPLICANT SIGNATUREL. L_9ayi_______
i f.' DATE . 3 l
Jr
_ APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture _ Quantity - Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher „t C 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 •
I
I .
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 PLUMBING PERMIT FEE $ ��
The minimum surcharge for a
"fixed fee"permit is$S-Mir STATE SURCHARGE $ 1
1 v O TOTAL PERMIT FEE $ 5 S')
This Application Becomes Your Building Permit When Approved Paid /l 's�J1 Receipt No. ^ `//I/ o
Date \ B
s' -'
Building Official Date I ` c v y
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372