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. � pRip Date Rec'd
� �� CITY OF PRIOR LAKE PLUMBING PERMIT
� �
���'NES��
1. Blue File pERMIT NO . �� ' �
. 2. Gold CiTy
3. Yellow Applicant
lease or 'nt and si n at bottom
DRES� � � ZOI�TING (oflFice use)
I � �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ��
(Name) � (Phone) '
(Address) �, � (�� �'"p�
APPLICANT Champion Piumbing
(Name) # �1770-PNi (Phone)
651-365-13
(Address) Dodd Rd.
(Address) Eagan, MN 551 (City) (Zip Code)
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(Contact Person) � � (Phone)
APPLICANT SIGNATURE DATE S � � �
APPLICANT PLEASE COMPLETE BELOW
QuanH T e of Fixture uanti T e of Fizture
Bath Tub with or without shower Rou -ins
Dishwasher ater Heater
Floor Drain Wa er o ener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
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 �st $��� �`� Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid �--� / J --� Rec p No. �,� ��
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Date 5 � � � �.Z
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
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