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0 H CITY OF PRIOR LAKE PLUMBING PERMIT
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INNESO
1. Blue File PERMIT NO. !0 , 6 97
2. Gold City /
3. Yellow Applicant
(Please type or . rint .--
an st n . • . ottom)
ADDRESS I / f' 5 f ��QCI C E ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I K; ' t-/h (Phone) (P12
i'12 1) 1
(Address) CUM
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
651 - 365 -1340
(Address) • .••• z .
(1)MN 55123 (City) (Zip Code)
F 1ekj (Contact Person) €CCIA X a I (Phone)
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APPLICANT SIGNATURE DATE U ' 13 \D
.G
APPLICANT 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
Residential, Additions & Alterations $49.5)
Estimated Cost $ Building Permit # C
PLUMBING PERMIT FEE $ 4ct 50
STATE SURCHARGE $ � . ')
TOTAL PERMIT FEE $ )k
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 54_ 5t Re pt Np. / 0 14 ,
Building Official Date Date V (t3 ( ( '
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
1
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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