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O 4 vitro Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
IA'NESD'
1. Blue File
2 PERMIT NO /
. Gold City O
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
53 S9 Cardinal ?i Trctii 5E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) Od V1-L f)frovv fl (Phone) / 5 2 L "
(Address) S /I(Y fflor L c r& 1 rY) t\J .. c):67
APPLICANT
(Name) Cham Plumbing (Phone)
It 61770 -PM
(Address) 651- 365 -1340
.7 Dodd Rd.
� (� rg MN 55123 (City) (Zip Code)
(Contact Person) 1 I J (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quanti Type of Fixture Q iiantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
ost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ i fq year effective "�
July 1, 2010, until June 30, 2011. STATE SURCHARGE lJ •3►'
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is is beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 Sb Re t No. / /6
(p l/
Building Official Date Date,'
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lat e, Minnesota 55372 t-ti5
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