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04 p �,�� Date Rec'd
,�, CITY OF PRIOR LAKE PLUMBING PERMIT
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�5�� I. Blue File pEg�IT NO .
2. Gold Ciry ��—���
3. Yellow Applicant
IC88C OI � t 811(� 8 2t �fOttODl
ADDRESS ZONING �o�re �)
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LEGAL DESCRIPTION (oflFice use only)
LOT BLOCK ADDITION PID
OWNER � 1 (Phone) d� � �� ! J / Z �
(Name) � �
(Address) �� � c � �
APPLICANT Champion P�umainc�
��e) �t'�� - �'hone)
(Address) 65� -�6�` � �4�
(Adc1��D Dtadd �O�d (CitY) (Zip Code)
(Contact Person) ��aCi, MIV ��123 (Phone)
APPLICANT SIGNATURE DATE ' ��� �
APPLICANT PLEASE COMPLETE BELOW
uanti 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 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
FEE5CHEDULE
Industrial, Commerciat & Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Pertnit #
The Minnesota Statutes § 326B.148 pLUMBING PERMIT FEE $ ��
"SURCHARGE" has been extended
until June 30, 2013, STATE SURCHARGE $ �
The minimum surcharge for a TOTAL PERMIT FEE $ �S� �
"fixed fee" permit is $5.00
i ,.,, ,-, .,.,.,,,..__.. ____ ___.ing Permit When Approved Paid �� � Receipt No. � 7 7�
su�tat�e ottEcia� Da� Date `,/ � By �
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24 hour notice for all inspections (952) 44'I-9850, fax (952) 447-4245 � n
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 v�'
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