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CITY OF PRIOR LAKE PLUMBING PERMIT as .9 �3
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1. Blued Fiiitty PERMIT NO.f3 1/z3
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3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
aq14er 1ae Las R1
LEGAL DESCRIPTION(office use only)
LOT i. BLOCK 2—ADDITION ,4'&i e 40:///27 pm 193-- 47W-312 —i0
OWNER
(Name) , I A m es ( <N /� \
( nLe S l i,e, (Phone) 6 - `o?010 - - `e ke
(Address) SCi rry)2_
APPLICANT
(Name) Appliance Connections Inn (Phone)
(Address) 12850 Chestnut Blvd.
Sty, _ - -, MN ,`,5/79 (City) (Zip Code)
• -45-4803
(Contact Person) (Phone)
APPLICANT SIGNATURE li/' (ArY\AJV,,,,t..\+., PDATE 101 ,9-/ -2-613
J
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher I 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
The Minnesota Statutes§326B.148 FEE SCHEDULE
"SURCHARGE"has been extended 1 of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The minimum surcharge for a
"fixed fee"permit is$5.00 st $ Building Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .56---
TOTAL PERMIT FEE $
(Office Use Only) , •
This Application Becomes Your Building Permit When Approved Paiai,i csV Receipt No. //0 / / Al
(0 ,1 f 1),:
1 . MBy
Buri¢ i ate
.400
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372