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04 YRIp�P Date Rec'd
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CITY OF PRIOR LAKE PLUMBING PERMIT
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Gol o Fi'` PERMIT NO
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3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(orrice use)
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LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Name)OWNER Ale,K (Phone) q62 -V//5"-
(Address)
V// -(Address) 3U \ cW),C. -"A"Ztk k -�Y-ZI► �,�Li
APPLICANT champion Plumbing
(Name) PC 000308 (Phone)
(Address) 651-365-1340
(Address) 3670 Dodd Road (City) (Zip Code)
Eagan, MN 55123
(Contact Person) (Phone)
Ari 1 r,
APPLICANT SIGNATURE _ DATE
APPLICANT PLEASE COMPLETE BELOW AI//t3
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower
Dishwasher f (Water He-ate
Floor Drain �afee fleuei
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
4iO /
Residential,Additions&Alterations $49.50
Estimated Cost $ - BuildingPermit#
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"SURCHARGE"has been extended
PLUMBING PERMIT FEE $ The minimum surcharge for a
STATE SURCHARGE $ "fixed fee"permit is$5.00
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Pail I eceipt No. Ql /
Date// IV By
Buildin Official Date 4 t 1/4'v A
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372