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CO1 PRip� Date Recd
i( CITY OF PRIOR LAKE PLUMBING PERMIT -
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1.sluea Fiiit PERMIT NO. l /9/7g
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/ 3.Yellow Applicant `•.
(Please type or print and sign at bottom) -
ADDRESS ZONING(office use)
3354 iid i Id fo' ( -
LEGAL DESCRIPTION(office use only)
/ADDITION 74e Gt/LG(/�- / �"�%(L e0 PID ( 5- 37.5 X036
LOT BLOCK 7-)
OWNER
(Name) (,�� /� (Phone) .5a-0202/- f--11d.
(Address) 54 rn Q,i
APPLICANT
(Name) Appliance Connections Inc. (Phone)
(Address) 12850 Chestnut Blvd.
\A 5 :•;,,,t•! , MN 55379
5-4803 (City) (Zip Code)
(Contact Perso Y1 Yi& i e...-ip �� (Phone) l)( J`??f /7'?c
1 APPLICANT SIGNATURE AtliIa . ,i �DATE / / 2o/S
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity - Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher b j 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 •
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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 .
-
The minimum surcharge for a PLUMBING PERMIT FEE $ '7`
"fixed fee"permit is $' STATE SURCHARGE $ Ldie
//VC,
TOTAL RMIT FEE $ V
This Application Becomes Your Building Permit When Approved Paid /() `0 Receipt No.3( 0
Building Official Date Date l / ` "1. By
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372