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CITY OF PRIOR LAKE PLUMBING PERMIT e-" $NNES
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1. Blue File Date Rec'd
PERMIT NO.
2. Yelp
3. Yellow A pow Applicant - 1 L „
(Please type or print and sign at bottom)
ADDRESS ^ � � � ` ��� S4. ZONING (office use)
1 (
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Q /'l C
(Name) 0 Z (Phone) " Sd • ��V" J
(Address) s e Rio( 1,a4 lY) S J 9 L
APPLICANT Chanlpiun Plumbing
# 61770 -PM
(Name) 651- 365 -1340 (Phone)
3670 Dodd Rd.
(Address) Eagan, MN 55123
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE ��'' % DATE - l C — 1
APP ICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -.
Dishwasher ` ater 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 $ c9C)d P Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ 5- ci 00
TOTAL PERMIT FEE $ SW $ D
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5 - 4 _,. ,3 - 0 Recei o. 46 4
Date Zr. Z7 IL By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ^ n