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CITY OF PRIOR LAKE PLUMBING PERMIT
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�. B��e File PERMIT NO /��a�
z. c�ia c;ty •
3. Yellow Applicant
CASC OY � Y 811Q St bOttOm
ADDRESS� � �� � ZONING �ot�ce �>
3 �- � I� ,-� l�
LEGAL DESCRIPTION (office use onty)
LOT BLOCK ADDITION PID
OWNER
(Name) � (Phone) ���
(Address) �Gt/Yr—�� �o'�
APPLICANT Champion Piumbing
(Name) �c� 7�n_DAA (Phone)
651-365-1340
(Address) 30�9 Clodd R�-
(Adclress) Eagan, IVIN 55123 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 7` y �' ����"
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fiature
Bath Tub with or without shower
Dishwasher Water Heate
Floor Drain Water Softener
Lavato Bat�room Sink Stand Pi e ashin 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
FEE SCHEDULE
Industriai, Commercial & Multi-family 1% of job cost with a$49.50 minimura Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
st $ ��� Buitding 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 � �—
"fixed fee" permit is $5.00
T6is Appticatian Becomes YourBuilciiag Permit When Approved Paid�� J� Receipt No sL
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Date � � �y � By �
B�ua�g ornc�i nace r
24 hour noNce for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minaesota 55372 ,,^
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