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PRIp C.,,,/ Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 4-, 5.4 a
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1. Blue File PERMIT NO. I Z 0 1 ' 2. Ye II App
(Please 3. Yellow A
( type or print and sign at bottom)
ADDRESS r 75 33 b re �� y Porn* Rd SE ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Na / . , / \ U sp .rV (Phone) q59 - / ' —
(Address) Same 4
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
651 - 365 -1340
(Address) 3670 Dodd Rd.
(A ), MN 55123 (City) (Zip Code)
(Contact Person) ,becc I, (Phone)
APPLICANT SIGNATURE , � '"0` DATE 4 / — / v
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APP ICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher i Water Heater
Floor Drain Water Softener
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 $49.50 minimum Residential, New One & Two - Family $149.50
t� Residential, Additions & Alterations $49.50
Estimated Cost $ V• 06 Building Permit #
PLUMBING PERMIT FEE $ 4- 50
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
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This Application Becomes Your Building Permit When Approved Paid 5 U U Rec i t No. (6,3
Building Official Date Date 4 (. B .
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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