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-" CITY OF PRIOR LAKE PLUMBING PERMIT
47N —SI.Blue File
2 GoldCity PERMIT NO.
p 1 I Z
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I'1(0902 IA); GI \Jì S
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) / 11.. (Phone) ��(� '" I "'
(Address) Q
APPLICANT
(Name) (Phone)
Appliance Connections Inc.
(Address) 12850, Chestnut Blvd.
TAX03 379 (City) (Zip Code)
(Contact Person) . (Phone)
APPLICANT SIGNATURE 'pligarint
M DATE /riI
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
CQ 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 Pe it#
PLUMBING PERMIT FEE $ J
STATE SURCHARGE $
TOTAL PERMIT FEE $ -Z,
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 54 c Rec t N 1/o
Date / By 6
Building Official Date `
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372