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F Ri Date Rec'd
t CITY OF PRIOR LAKE PLUMBING PERMIT
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z. PERMIT NO. ! I I
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1s2561 cq ar c ite,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER M A 1 - 91e5 `�cb
(Name) /V L (Phone) -Loeb
(Address) sc r, r Lag M 5
APPLICANT
(Name) Champion Plumbing (Phone)
# 61770 -PM
(Address) 651 -365 -1340
(Adda6?)0 Dodd Rd. (City) (Zip Code)
Eagan, MN 55123
(Contact Person) (Phone)
APPLICANT SIGNATURE i DATE _WEL)
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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
The Minnesota Statutes § 326B.148 ost $ Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ C l O 0
until June 30, 2013, STATE SURCHARGE `1
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid 1 L &-) Rece p No4
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Building Official Date Date ( By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 I v 11-
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 �' (�c
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