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F p RIp Date Rec'd d
CITY OF PRIOR LAKE PLUMBING PERMIT
/IIIN �
1. Blue File PERMIT NO . qo�
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
70-n Crr 5 Send r4 34-. 3E-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � '[ Q �!� (�
(Name) ck (Phone) (012 - U -I v r vZ-3 -0-
(Address) . > C J R)( lCL► ► t IM' d
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
651 -365 -1340
(Address) 3670 Dodd Rd.
(A , MN 55123 (City) (Zip Code)
(Contact Person) 0 5 0 - (Phone)
APPLICANT SIGNATURE / / //✓ 1 / i �. DATE v
,.
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
E'" + +m. +P" Cost $ Building Permit #
The Minnesota Statutes §326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ Li • So
until June 30, 2013, STATE SURCHARGE $ (-1- = O.ov
The minimum surcharge for a TOTAL PERMIT FEE $ 50
"fixed fee" porrnii. is $5.00
This Application Becomes Your Building Permit When Approved Paid 5 . c.z) Rece No. ¥ (13
Building Official Date Date y 2.3 r ` 1 By . 5 2�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 1 u J 7 7
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
4419