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CITY OF PRIOR LAKE PLUMBING PERMIT 1/ '
4 'NNESO
1. Blue File O
P ERMIT N. ,// , i i q o
z. cola city '
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
13 0 12 7e CC e_vs Pa65 n a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) R R 0S s (Phone) Iola - a u 1- 5 51,
(Address)
APPLICANT
(Name) (Phone)
CULLIGAN WATCH CONDITIONING
(Address) 6030 CULLIGAN WAY
MINKA, MN 55345 (City) (Zip Code)
(952) 933 -7200
(Contact Person) (Phone)
APPLICANT SIGNATURE 1_ I DATE 10 -
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 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 $ ,a Building Permit #
"SURCHARGE" has been extended .-SO PERMIT FEE $ 4�
until June 30, 2013, STATE SURCHARGE $ S. 0 Ufr6
The minimum surcharge for a
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ „5 . 5 U
This Application Becomes Your Building Permit When Approved Paid 54 s--c, Rec 1 t No.613/
Date JJ ( , By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372