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R10Date Rec'd
Ec.0CITY OF PRIOR LAKE PLUMBING PERMIT
I.Blueit PERMIT NO1c,2.Goldd CCity �
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3c53
P Ouiv\OS(A/ Cif 9g
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
NER(NameOWn ./ S+zrri btlt "(Phone) ;1151"fr OT
l
(Address) n 3Li 0 ti --0100 t-) C�tr
APPLICANT
(Name) Champion Plumbing (Phone)
(Address) PC 000308
(Address) 651-365-1340 (City) (Zip Code)
(Contact Person) 3670 Dodd Road (Phone)
Lagan, MN 55123 /� J(�
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -in
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 $ T '¶6 Building Permit# The Minnesota Statutes§326B.148
PLUMBING PERMIT FEE $ "SURCHARGE"has been extended
STATE SURCHARGE $ The minimum surcharge for a
TOTAL PERMIT FEE $ Y-1,50 "fixed fee"permit is$5.00
(Office Use Only)
91 A
This Application Becomes Your Building Permit When Approved Paid ;MC eipt No. .
Date •
Buiidine Official Date .1/' .0 L.
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 `�