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i 4 pRi Date Rec'd
,� , e CITY OF PRIOR LAKE PLUMBING PERMIT
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4 fIi'NESOc P
I. Blue File PERMIT NO .
2. Gold city // -
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 I I - 13`I,�G,I ---- Tfa, \ 5s 3 7a
.
LEGAL DESCRIPTION (office use only) ',/l.,
LOT BLOCK ADDITION PID
OWNER (�
(Name) K N5 (Phone) 9 a -44b-L3 I o
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(Address) ,T1 1 10 k'{ c, t \ I f G 1
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
(Add) 933 - 7200 (City) (Zip Code)
(Contact Person) (Phone)
s 1
APPLICANT SIGNATURE ____ I_.. DATE 1 - 1 - I 1
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 1 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 1st $ c aOb ,00 Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ L cl 50
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ S. 00 -.4A
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ S S O
is a& beginning July 1, 2010 4
This Application Becomes Your Building Permit When Approved Paid 9 1 e eipt 341 I
Date `�I co J y
Buildine Official Date d .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372