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4 P RI Date Rec'd
? � CITY OF PRIOR LAKE PLUMBING PERMIT
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M /NNESO'° I. Blue File
z. cola City PERMIT NO. / / 5 o Z
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
v L Pno(Jocd�S .s
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER l
(Name) �. r (Phone) .0 / - • 0 - 6 •
&A.NY"\-e-- (Address) t C>^( L c -t., - new N c s 590-
APPLICANT Champion Plumbing
(Name) # 61770 (Phone)
651 - 365 -1 : 340
(Address) 3670 Dodd Rd.
(Address)) , M
EaganN 551 (City) (Zip Code)
(Contact Person) K.{-‘.s \./ , (Phone)
APPLICANT SIGNATURE DATE C' "1 _ 1 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower
Dishwasher 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
st �T
P� DO C Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ Si, SO
is S5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 521 Rece'. . o. / j / //_
Date / By
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
/ 03&33 /