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CITY OF PRIOR LAKE PLUMBING PERMIT
a *NNeses"
I. G Fie PERMIT NO.
2. Y City d8• 8 O ,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4 1 1 115 R)rAyieitni Tr I SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
WNER (f 952 C1-J
(Nam ) Ck fes hop F� l (Phone)
(Address) Q / P170 ¥tk , 5537'2-
APPLICANT
(Name) Champion (Phone)
(Address) 651 -365 -1340
? 3 , k7 d ■ ! • • d Ra. I uu (City) (Zip Code)
Eagan, 55123 -1339
(Contact Person) MI S 0 '("J (Phone) C
APPLICANT SIGNATURE ,ltd ✓. %, _' DATE I -23
AP ' LICANT 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 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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid.3 00 RI No. 9D2
Date C. or
Building Official Date .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447- 4245��Q
16200 Eagle Creek Ave., S.E., Prior Lake, MN 55372 -1714 �� 00
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