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_ CITY OF PRIOR LAKE PLUMBING PERMIT
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4/ A r NESO
1. Blue File PERMIT NO .
2. Gold City /0 .. //3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
IStlb Island \) w N NW
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
I /
� 1 • / 1.�� .710i I r� (Phone) - 1 � (/ XI
(Address) scare, Pr`\()( �t / 1 I S537--E.
APPLICANT Champion Plumbing
(Name) # 61770 -PM (Phone)
(Address) 651- 365 -1340
(Address) aga Dodd 55123 (City) (Zip Code)
CC /� Eagan, MN 5 5123
(Contact Person) 1'( \v l J • (Phone)
10
APPLICANT SIGNATURE � `� DATE 0-1 �
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 § 326B.148 t 01 ;0 r Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July I, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ S ()
is 5_5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 - `� Rec pt No. 6, (� 1/
Date
Buildine Official Date 1 `7 r, /U
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 q 8 09 cpr