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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue City PERMIT NO. 95z-
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS �� ZONING (office use)
¶OS(P PU iY,, ( ,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Na WNER rte ; +h 1 Vce (Phone) ' _ t(9- i J �S J
(Address) ( T ► i oo L I....a MO SS '-
APPLICANT Champion Plumbing
# 61770 -PM
(Name) 651 365 -1340 (Phone)
(Address) 3670 Dodd Rd.
( ddress) Eagan, Mil 55123
(City) (Zip Code)
(Contact Person)
yirs U , (Phone)
APPLICANT SIGNATURE
ljg/'." DATE t —1 ,3 <
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APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower ' A te rilli Dishwasher
Floor Drain Water o tener
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
Estimated Cost $ C9 a) Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ 11140
"fixed fee" permit is $5.00
This Application Becomes r DUI ,wilding Permit When Approved Paid .53 Rec t No. A/ /A�--
Date Q �J / `� Y',
Buildine Official Date / �/ / .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 1 ()Ss 3 ) C n- -