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� pRI� Date Rec'd
� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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�fNNES��� �
1. Blue File pERMIT NO
2. Gold City � � � / _
3. Yellow Applicant �� ��'�
lease or 'nt and si n at bottom
ADDRESS ZONING (ott use)
v ���'G� c�f� �
LEGAL DESCRIPTION (o£fice use only)
LOT BLOCK ADDITION PID
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(Address) �} (��J
APPLICANT Champl�n ''�UI°flbl�lg
(Name) ��,�� �.. (Phone)
651
(Address) ��n n,,.��, o,�
(��)NEN 55123 (City) (Zip Code)
(Contact Person) I� � (Phone)
APPLICANT SIGNATURE DATE `L �
APPLICANT 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 Bathroom Sink Stand Pi e Washin Machine
Laund 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
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
T:� i�JI1SSiIP St?r_u±es s 326B.148 ~ost $ Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ -�
until June 30, 2013, STATE SURCHARGE $ S. �.50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid F �./I 1 Rec ipt p, I� y�
7 � �i �SlV
Date ` l � By
Buildin� Official Date � �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372