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L� CITY OF PRIOR LAKE PLUMBING PERMIT
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1 A'NEso
1. Blue File
2 Gold PERMIT NO // z
. l App ��
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS n ZONING (office use)
I (P O(o1 c 3
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((711ER jan'e4 t rOC) ( N O U s (Phone) 15a" a g. (
COS
(Address) Sct,vv\ �i Pricrc Lce m IQ s 3 C
APPLICANT Champion Plumbing
# 61770 -PM
(Name) 651 - 365 -1340 (Phone)
3670 Dodd Rd.
(Address) (Address) Eagan MN 55123 (City) (Zip Code)
(Contact Person) \ O. (Phone)
APPLICANT SIGNATURE DATE 1 - 1 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -.
Dishwasher 1 ater Heater
Floor Drain ater 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 lost $ d-0 (9. C Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ Sq. S
This Application Becomes Your Building Permit When Approved Paid 9, rn Re ) No. j ,7I v
Date 1 1 I B
Buildine Official Date l +
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
i CP