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CITY OF PRIOR LAKE PLUMBING PERMIT
slue Fik PERMIT NO. [/�fj�'
Gotd City /!
3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
S Cp &CASS tA)COCICi SW
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(ONWNER t /c(.. r' (Phone)
(Address) ScL
SS E �'�---
APPLICANT
(Name) Champion Plumbing (Phone)
PC 000308
(Address) 651-365-134(1
(Addr )70 Dodd Road (City) (Zip Code)
(Contact Person) Ea. . M 123 (Phone)
al A; ,
APPLICANT SIGNATURE v �' ® `"" DATE V ' l
A
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower
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
t $ (2,°a Building Permit#
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ Sy 5 e)
This Application Becomes Your Building Permit When Approved Paid ` Re i No.
Dates LL /
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