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CITY OF PRIOR LAKE PLUMBING PERMIT
I. Blue File y /3„ V PERMIT NO. /, v
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2. GoW Cit
3. Yellow Applicant ��..JJ
(Please type or print and sign at bottom)
ADDRESS ' ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER - {PO° W
(Name) .A. � , a _ Mn (Phone) s
(Address) SCILA'n-e— , 6)
r Y L€ rn J
(Name)
APPLICANT Chsmpl ®n Plumbing (Phone)
RC 000308
(Address) 651 -365 -1340
(Address) 3670 Dodd Road (City) (Zip Code)
Eagan, MN 55123
(Contact Person) !!� Y (Phone)
APPLICANT SIGNATURE DATE ` 13
...1.6,,,if#72_____
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower
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
The Minnesota Statutes § 326B.148 t $ Building Permit #
"SURCHARGE" has been extended
The minimum surcharge for a PLUMBING PERMIT FEE $ It ,`-')
"fixed fee" permit is $5.00 STATE SURCHARGE $
TOTAL PERMIT FEE $ r
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid,` 5
. Receipt No. 944 7/
Date 2// 743 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
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