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I h, CITY OF PRIOR LAKE PLUMBING PERMIT 2_-t7‘12--
JANESOs•P / /
1. Blue File
z. cola city PERMIT NO� `/
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4' y2( /-/air,jabj{d - Trcgl NE--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER p • , - cit It ' II 41111A
(Name) C 1 I_, L -J (Phone)
•
(Address) SC ,,42. Wi`,csr L - — e , MINI, S s a-
Champion Plumbing
APPLICANT # 61770 -PM
(Name) 651 -365 -1340 (Phone)
3670 Dodd Rd.
(Address) Eagan, MN 5512
(Address) (City) (Zip Code)
(Contact Person) :1)0,..A (Phone)
APPLICANT SIGNATURE DATE — «—
AP ICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
eReftrozi
Bath Tub with or without shower
Dishwasher i ter 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 Jst $[j 15' 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 $ S , SO
This Application Becomes Your Building Permit When Approved Paid f _„ Re pt Nob /J)
J (Jp
Date 2 , /7 /I--
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