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: e CITY OF PRIOR LAKE PLUMBING PERMIT
I n NESD��
1. Blue File PERMIT NO . / / 52 1
2. Gold City ! l
3. Yellow Applicant t
(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 (�` rr'', � ('� � /(� (� �
(Name) �� Ch�W �� � �,1 \ 1 ` � 1 (Phone) - 1 - (/ -/ . `i q -3
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(Address) ` / r O ( lL )l-- f Y ► t'0 S s J 3�
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
b51- 365 -1340
(Address)
3670 Dodd Rd.
(Address) Eagan, MN 56123 (City) (Zip Code)
(Contact Person) \\(-).-- D . (Phone)
APPLICANT SIGNATURE DATE CO 1 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rot>. -inc
Dishwasher ater 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 'ost �• Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit � A 0
is beginning July 1, 2010 TOTAL PERMIT FEE $ A `
This Application Becomes Your Building Permit When Approved Paid 54, co Re pt No. / 3(3 _,
Date1 B
Buildine Official Date l( 7/1// ( (
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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