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O PRIO Date Rec'd
.4 c CITY OF PRIOR LAKE PLUMBING PERMIT
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0 dtESOC� I. Blue File P ERMIT NO.
2. cold City fL -43 j j ---
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRE S ZONING (office use)
1 /Ca_15 5V,K(A. t irc,;,)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Nam ER us OV (Phone) � D 9 . `�
(Address) `V1iy..--e---
APPLICANT Champion Plumbing
(Name) PC 000308 (Phone)
651 -365 -1340
(Address) 3670 Dodd Road
(Address) MN 55123 (City) (Zip Code)
(Contact Person) �`° VN (Phone)
APPLICANT SIGNATURE �4eIe :1I i DATE {
_ lr '/
Air
APPLICAN LEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Ri - _
Dishwasher
Floor Drain : - . - -r
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 #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ 50
The minimum surcharge fora TOTAL PERMIT FEE $
"fixed fee" permit is $5.00
11113 rtppu aaiun yca:uiia uUR l,ua.ding Permit When Approved Paid Receipt No. i 7‘
PI. 31 Date j l � / By i .7b� -�C./
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