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(.(pRfo Date Rec'd
4 CITY OF PRIOR LAKE PLUMBING PERMIT 'CO, ,/ //
4fl A'NESO
1. Glad File Yell A PERMIT NO . // 0
3 pp / V
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1109 log 1,11 A„fax -- Tir _SC -7
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) 1.-.0.1( k q PI 0 r (Phone) b r a- a 3 7- 83 L3
(Address) 1109 A q W \ \ COPY rm SS — v SE
APPLICANT CULLIGAN WATER CONDITIONING
(Name) (Phone)
6030 CULLIGAN WAY
(Address) MINNE_TONKA, MN 55345
(i 9 s 33 -7200 (City) (Zip Code)
(Contact Person) (Phone)
L APPLICANT SIGNATURE L
DATE - (-1 i
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain I 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 ;ost $ c 00 . 00 Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 41‘ 50
July I, 2010, until June 30, 2011. STATE SURCHARGE $ S.. b0 ,.5$
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ . Sy . 5 0
is 55, beginning .luly 1, 2010
This Application Becomes Your Building Permit When Approved Paid s -/) Recei t No .6 11 7 / , 0 9q
Date I , ` 1,1 By
Buildine Official Date l "�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372