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� PRIp Date Rec'd
� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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l. Blue File pERMIT NO . `�
2. Gold City
3. Yellow Applican[
lease or ' t and si at bottom
ADDRESS r � `�/ ZONING (ott'ice use)
f �
LEGAL DESCR�TION (office use only)
LOT BLOCK ADDTTION PID
OWNERI ,�,, ��� . �� q �j?p
(Name) /�X� �����7 ', (Phone) � � Z` � ` ZS t7O �
(Address) GL,r'Y1�QJ
APPLICANT Champion Plumbing
(Name) (Phone)
(Address) 6� 1
P�S N 55123 (City) (Zip Code)
(Contact Person) �r� � (Phone)
APPLICANT SIGNATURE DATE s � —
PLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain � Water Softener
Lavato Batl�room Sink Stand Pi Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
EDULE
Industrial, Commercial & Multi-family 1% of job cost a 0
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 �st $ ui rmit
"SURCHARGE" has been extended
until June 30, 2013, pLiJMBING PERMIT FEE $
The minimum surcharge ST •► �
"fixed fee" permit is 5.00 TOTAL PERMIT FEE .����--� ✓
This Applicatlon Become� YBUr Building Permit Wtren ApprovCd ' Paid �� � eipt No. y�„ � � O
• ((J
Dat i
Buildin¢ Official Date i { '
24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ���I �(„
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