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CITY OF PRIOR LAKE PLUMBING PERMIT
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41 rNNES6 P
1. Blue File PERMIT NO
2. Gold Airy b l
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
r c 1 qa 9 Sum 0,1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
# (Name) Sf t� w)r\ - • I # # (Phone) CO / a - l a
(Address) Sctiyre
APPLICANT
(Name) Champion Plumbing (Phone)
# 61770 -PM
(Address) 3 6 0 Dodd Rd.
3
(Address) Eagan, 3670 o Rd. (City) (Zip Code)
(Contact Person) Kfl& ' , (Phone)
APPLICANT SIGNATURE - `�' "" .... u.. DATE
11 -4 0
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower R
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
,t $ _a 6° Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ 9 ,s°
year effective STATE SURCHARGE $ 759 —
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is 51, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid �_ I No. / 11
Date L 1 to - Ce
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 C
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 q 81 9 4sya