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4 CITY OF PRIOR LAKE PLUMBING PERMIT 30,/0
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I. Blue File
2 cola city PERMIT NO. /0 57g
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1390 Cozchiv&n NE ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER / .—
(Name) 1 if • ' 1L er (Phone) 1
(Address) S1L!( r-2 7t)
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
651 - 365 -1340
(Address) 3670 Dodd Rd.
�/� (;)MN 55123 (City) (Zip Code)
(Contact Person) Pa eL l (Phone)
APPLICANT SIGNATURE /` ' ` -- DATE 69 - 4 1 0
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APPLICANT 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 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 $ 50. 00
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 56 / Re. - No or e-
Date / , 30 , / 6 B le-r)
Buildinn Official Date cl� I • 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 i (3 4
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
K)C174