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CITY OF PRIOR LAKE PLUMBING PERMIT Y l ; l�
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• 3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
,4.9311 �� / K i JV � 6537 R2-
LEG iL DESCRIPTION(office use only)
_ LOT BLOCK -' ADDITION ' e)/'t- S 4c f PID 2 5 �. ®D/ 'O
OWNER , 4 Q
/-C-VA//4 (Phone) 95:92-
/17 � 6
(Name) (Mar! O(Address) -- (SO/e —
APPLICANT
(Name) Appliance Connection e)
12850 C4-estmt BIVd.
(Address) $t aJI pee,MN 55379
(Address) 9$2.4454806/ (City) (Zip Code)
J
(Contact Person) Q m I,e 1,0,e /
(Phone)
APPLICANT SIGNATURE 11, , Zt....- �1 I / DATE _JR/0 -
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without showerRough-ins
Dishwasher
r Water Heater
Floor Drain _ Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink. , Sewage Ejector
Shower Stall _, BKltflow 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 PLUMBING PERMIT FEE $ �l `
The minimum surcharge for aSTA E SURCHARGE $ L '"
•
"fixed fee permit-is 61 TOTAL PERMIT FEE $ ___ 0
Permit When Approved r Paid go Receipt No.I.A.
This Application Becomes Your Building ��' �
Buildina Official
Date Date •9) ; i / By S -
24-lloui-.notice for all inspections(952)447-9850,fax(952)447-4245
- .4646 Dakota Street S.E.,Prior Lake,Minnesota 55372