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Q Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
I. Blue File
2. Gold City PERMIT NO. I D 0 I f
0 D
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
35 2- ) S)ane( 61A/ CG r
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Ti 3r (Name) 1 �'r O Xr) (Phone) 9 5 y I" o 07
(Address) LSar, -, l ri3 ( Lake )(4. NI 9S31
t
APPLICANT champion Plumbing
(Name) # 61770 - (Phone)
651- 365 -1340
(Address) 3670 Dodd Rd
()MN 55123 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE .r" M w DATE
3 -11 -10
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher ( 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
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ (
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5U- Oc)
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid 5 0 00 Re ei No. 51808
Building Official Date Date3. 22.,1 v
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 24/ [05J(
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