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a' CITY OF PRIOR LAKE PLUMBING PERMIT (. WA)
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MI 1'NESd iP
1. Blue File
2 cola city PERMIT NO. !/ / z z (o
.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
'— / SI 0 r vi tuk,f T' SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �, �
(Name) C ( rn �` a ( Phone ) (pia, 41 1
(Address) SGAVh ve- P or Y.e ) I ► `� g 5 3 - 3- v�
APPLICANT Champion Plumbing
(Name) # 61770 - (Phone)
651 - 365 -1340
(Address) 3670 Dodd Rd.
(Address) Eagarr, MN 55123 (City) (Zip Code)
(Contact Person) K11 1 S 0 a (Phone)
APPLICANT SIGNATURE 4/ _iiG(llrirc DATE ) WI 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Roue I
Dishwasher
Floor Drain a - . ener
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
v
The Minnesota Statutes § 326B.148 ost $ 0 - v Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ q q -.
The minimum surcharge for a STATE SURCHARGE $ c.".bff
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ SH , So
This Application Becomes Your Building Permit When Approved Paid l ;IF a Receipt No., 44, 41
Date ` I 1 + , By l
Buildine Official Date r
U
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
1 0 60 6 39 .1,D