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Date Rec'd
(,, CITY OF PRIOR LAKE PLUMBING PEIl�IIT
�I,,'NES.,,P
I.2. BluelFile
ty PERMIT NO.
3.Yellow Applicant /� O�3
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/%/V fl/ YM (/ Zn /9r
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER /7, �/
(Name) /7/MV1� 7/f'7,�/2 (Phone)
(Address) /G/J O v (5,(A4_,,,,,„,2,/ ��.
APPLICANT
(Name) (Phone)
Champion Plumbing
(Address) PC 000308
(Address) 651-365_1340 (City) (Zip Code)
(Contact Person) 3670 Dodd Road (Phone)
APPLICANT SIGNATURE
Eagan, MN 55123 DATE a /
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -.
Dishwasher j c ater Heate
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 $ e:7 Building Permit#
The Minnesota Statutes§326B.148
"SURCFIARGE"has been changed for one PLUMBING PERMIT FEE $
year effective
July 1,2010,until June 30,2011. STATE SURCHARGE $ 50
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $ �7 `- • 50.50
is 35,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid so .5-0 Reyipt No. 2:701
Dat ` By
i,Building Official Date c -. 1 , i)
24 hour notice for all inspections(952)447-9350,9350,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372