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P,�Ip� Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
v �'r;
,NNESOly, I. Blue File
2. Gold City PERMIT NO. E (6( Q,
3. Yellow Applicant 1 v
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
11-0 33 Hill9ide Cir n1W 55-5-1a
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) Phi i i p Ren5icW (Phone) `j`52-90G - 32,7-7
(Address) j
APPLICANT Champion Piimbing
(Name) (Phone)
PC 000308
(Address) 651-365-134(
( g7O`bodd Road (City) (Zip Code)
(Contact Person) Eagan, MN 55123 (Phone)
APPLICANT SIGNATURE ° Athek DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Ro -. s
Dishwasher t ater Heat
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
lost $ SOO Building Permit#
The Minnesota Statutes§326B.148
"SURCHARGE"has been changed for one PLUMBING PERMIT FEE $ 60
year effective STATE SURCHARGE $ .50
July 1.2010.until June 30,2011.
The minimum surcharge for a"fixed fee" permit TOTAL PERMIT FEE $ O.SC)
is 35,beginning July 1,2010 .
This Application Becoifies Your Building Permit When Approved Paid 5b
Rece. t No,, ---1 1Al
Date By "
Building Official Date es., (.. ( ,
24 hour notice for ail inspections(952)447-9350,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
ND