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CITY OF PRIOR LAKE PLUMBING PERMIT
�lnNESD�� 1. Blue File
2. Gold City PERMIT NO. �'/ J ul
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Naame) Y ACk\ Ver ! 0'1 e n iiO450 1I 1 (Phone) 1 52: W O 60
(Address) I1 9 fide/ tY Pri Di( 1 N - s ✓ J7_2_
APPLICANT
(Name) Champion Plumbing (Phone)
# 61 7 r0 - PM
(Address) 651 - 365 -1340
Dodd Rd. (City) (Zip Code)
/ ( `�'�ab, MN 55123
(Contact Person) S (Phone)
APPLICANT SIGNATURE DATE ( -I 4 -1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
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
The Minnesota Statutes § 32613.148 ost $ Building Permit #
"SURCHARGE" has been changed for one ((Q
year effective PLUMBING PERMIT FEE $ '"[_
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5. 6056—
The minimum surcharge for "fixed fee" permit TOTAL PERMIT FEE $ S1 t
is .,5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid
54, Rec ' o. & ,... 3 / /6 0
Date • / 1 B
Buildine Official Date G
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 I ,` (J �� _
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 50
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