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' O i PRI° Date Rec'd
ti CITY OF PRIOR LAKE PLUMBING PERMIT 3/2 - SI8
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I. Blue File PERMIT NO .
2. Yelp 13---0A5 ,
3. Yellow City
Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
':''3 \ e r
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER M ° A I / � / ii j j ( (Phone) r�r l� 4 l�
(Address) ScAV 4l \ cj
APPLICANT Champion Plumbing
(Name) PC 000308 (Phone)
651 -365 -1340
(Address) 3670 Dodd Road
(Address) (City) (Zip Code)
\�, Eagan, MN 55123
(Contact Person) ' be-LA, Ni (Phone)
APPLICANT SIGNATURE i DATE ` 1. G
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower t t ..-
Dishwasher 1
Floor Drain ∎ . - . • er
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
- 4> The Minnesota Statutes § 326B.148 $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ 50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ j ®
This Application Becomes Your Building Permit When Approved a ,(9\5/1\ ", Receipt No.bg4g 3
Date 5, (.s1-0 By f
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
011)
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