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4.1' CITY OF PRIOR LAKE PLUMBING PERMIT • 4'1 NNeso� r
1. Blue File PERMIT NO . �)
� 0 /�'
3 Gold City V Q�
3 Yellow Applicant 6/ U
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
110 101 f vaK)5Ih AVe SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER . - n /t�
(Name) * V C, 301 (r) S ( (Phone)
(Address) 6a/ML P r i 6 r L c Ve MO r 5 5 51
APPLICANT
(Name) Champion
(Phone)
651 - 365 -1340
(Address) 3670 Dodd Rd. #100
Eagan, I W3 -1339 (City) (Zip Code)
(Contact Person) IZ( ( S()1 O (Phone)
APPLICANT SIGNATURE A d '...+%f DATE
III , T
A ` PLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater
Floor Drain Water Softner
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 1% of job cost with a $39.50 minimum Residential, New One & Two - Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ So
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ ___570 • C►,)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 50 Receip o. 555 �, ov
• Dat 2 o b By
Building Official Date 'T ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
16200 Eagle Creek Ave., S.E., Prior Lake, MN 55372 -1714 307
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