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PRID Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
41'NNEsOcP I. Blue File
2. Gold City PERMIT NO.
3. Yellow Applicant `
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER n j , u 'n /' / •u
(Name) 1 JIJI e r s� (Phone) Y \ l pI ' 1 %3 / /U
(Address) 3GV!'Yl e pr_)o/ /_m ra r s9-.
APPLICANT Champion Plumbing
(Name) # 61770 - (Phone)
651 - 365 -1340
(Address) 3670 Dnriri Rd.
(Address) Eagan, MN 55123 (City) (Zip Code)
(Contact Person) L> (Phone)
APPLICANT SIGNATURE / / / /-/ DATE �� I
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower -inc
Dishwasher Voter 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
Fctim�r t r OSt $ c ° 0 , Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ ("1 /
?..
year effective STATE SURCHARGE $ < U,S�
July 1, 2010, until June 30, 2011. TOTAL PERMIT FEE $ S r .
The minimum surcharge for a "fixed fee" permit
is 55, beginning July 1, 2010
fi nis Hppncatllon Becomes Your Building Permit When Approved Paid6y co R /(0 .t No. 333
Date 7' ,
Buildine Official Date 2 /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 r�
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