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F A, t o CITY OF PRIOR LAKE PLUMBING PERMIT 573 i h3 "v 4
�'s °�� I. Blue File
2. Gold ERMIT NO . °�
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3. Yellow A ow App J plicant ('/✓�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
31 L C-J-. � t/
p ®
6 '
O (,�, �� d s , Q �
LEGAL DESCRIPTION (office use only) l ,, _//
LOT 6 BLOCK / ADDITION ` j/7 4r % & He &i t-0 PID ,2f •- 30 3 -6if) b G
(N me) R OA 00 1 r - WO O (9 d. n lid_ (Phone) q - t - a, - 67 7 s -
(Address) Satryli2.
APPLICANT
(Name) Appliance Connections Inc. (Phone)
12850 Chestnut Blvd.
(Address) Shakopee, MN 55379
(Address) 952 -445 -4803 (City) (Zip Code)
(Contact Person) Actmfe......ig 1 (Phone)
APPLICANT SIGNATURE '}'Yk,Q DATE 5 I ( ::D t 3
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
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ L1, S
STATE SURCHARGE $ - e A --:
TOTAL PERMIT FEE $
(Office Use Only) - 1 ' -. 6
This Application • . mes Yo Building P mit hen Approved ' ai -s a R eceipt No. i ,,f 1 n
5- 4115 p y �"� •
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B ' ne • fficial Date B 1 ...• �
• /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372