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P Itlp Date Rec'd 317),.4 7
H CITY OF PRIOR LAKE PLUMBING PERMIT , ,.,
'LANES °, �' 1. Blue File PERMIT NO
2. Gold City Oq /�7 2
3. Yellow Applicant (/(,�a,�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/L/ )8 Shad &h 7I N
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I / � t ` _ 1 � _ 3 Z
(Name) ! Q.n 4 Owens (Phone) ' S2 I / / 7
(Address) 1 % 914/1 y bead) ad) 1 r I .F._ t ?r! or �l'1 - i V)/) J "� ✓-7 ,9..., APPLICANT 1
(Name) Champion (Phone)
651 - 365 -1340
(Address) 3670 Dodd Rd. #100
Eagan, m1(0133-1339 (City) (Zip Code)
(Contact Person) kr t 3 Oi e-r) (Phone)
APPLICANT SIGNATURE d : = DATE I — 13 — 0 9
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 $ i q . 5o
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ bQ • a)
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid SD Recei.t No. S7 S
Date /
Building Official Date S G ` .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 3 Igo 9
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