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I CITY OF PRIOR LAKE PLUMBING PERMIT
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l. Blue File
2 Gold city PERMIT NO. I I e)
.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
\7e915 burr Opt Lit-N
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) ) OWNER U \ k c,, eec&e (Phone) 1S. -14140 O 016
(Address) S CA11r1 -I°j Pn 1-- 1 M Iv s s q-
APPLICANT Champion Plumbing
(Name) ft 61770 -PM (Phone)
651 - 365 -1340
(Address) 3670 Dnc1d Rci.
(Address) Eagan, MN 55123 (City) (Zip Code)
(Contact Person) \ 0 (Phone)
APPLICANT SIGNATURE / DATE ! 1 '`I ` 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -
Dishwasher 1 ater Heater
Floor Drain Water rottener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi- family I% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
E' ...:. _ — ' ';ost $ ,-Oj7 _ t" Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge fora TOTAL PERMIT FEE $ s 1 S o
"fixed fee" permit is $5.00
i nis Application Becomes Your Building Permit When Approved Paid 5q, 5 i R c ipt No. T
lJ
Date �f
Buildin¢ Official Date ( 1- ✓ 1 i 1 '
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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