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l./ Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
4NvE
soy°
�.Blue Filey PERMIT NO. IA,
l �
2.Gotd Cit J_'
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
2'111 #141"46n
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
Oevi
WNER
1111W---t— UPI \ (Phone) !5 4/5
(Address)
(Address) SRI' S Jct
APPLICANT
(Name) Champion Plumbing (Phone)
PC 000308
(Address) 65 l-365_1340
(Address) (City) (Zip Code)
3670 Dodd Road
(Contact Person) (Phone)
APPLICANT SIGNATURE .,� DATE Il 6'7//
O
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Ro
Dishwasher %1'•ter 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
The Minnesota Statutes§326B.148 $ Building Permit#
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ •i 50
The minimum surcharge for a STATE SURCHARGE $ "hr /
"fixed fee"permit is$5.00 TOTAL PERMIT FEE imr5.1• .
This Application Becomes Your Building Permit When Approved Paid SLJS12 R: - iit No.
Date Cz —� ( B
Buildine Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372