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pRlp Date Rec'd
4 CITY OF PRIOR LAKE PLUMBING PERMIT
4r ses.
I. Blue File
2.Gold City PERMIT NO./5 z
3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
—1-ff 11 ACQ, S
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) �`e�.�(l'� 'T*)t V NO( 1-(k. (Phone) Z I I 4111—
(Address)
ll 1 1—
(Address) 1
APPLICANT champion Plumbing
(Name) PC 000308 (Phone)
(Address) 651-365-1340
(Address) 3670 Dodd Road (City) (Zip Code)
(Contact Person) Ea9an
, MN 55123 (Phone)
APPLICANT SIGNATURE _j:,o:_o // DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher I 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
Estimated Cost $ 7. Building Permit# The Minnesota Statutes§3Z6B.148
"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 Paid 54 c 1 ceipt No. c);{5
Date
3 _ i i `Ic y JJ
Bafidin>:Officiai Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372