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o �e CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File PERMIT NO . 4_0 . Yelp / / O
3
3. Yellow City
Applicant {{ f
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
X47 &tic - SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER r /� �; �j
(Na d i1 + l ✓ a - eM c M (Phone) � '-` 73 jLJ
(Address) �citii Th V h , ( •
APPLICANT
(Name) Champion Plumbing (Phone)
(Address) # 61770 -
(Aeri 1-175-1340 (City) (Zip Code)
•
Ty odd Rd.
Eagan, MN 55123
(Contact Person) (Phone)
✓((
APPLICANT SIGNATURE DATE I 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 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 7ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ Ot
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 'SL( , 5°
This Application Becomes Your Building Permit When Approved Paid 5 Rece No ( 414
Date(6 Z/o t By
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 1 0 (a
4646 Dakota Street S.E., Prior Lake, Minnesota 55372