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J CITY OF PRIOR LAKE PLUMBING PERMIT
M ;A'NEs
1. Blue File PERMIT NO .
2. Gold City / / _
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
153 60
e-----", r I a j - . ' brQS F c I SE 553 ?•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1\ II
(Name) I, N G r� e.___ H C. `1 rvi ei (Phone) qs a y 7 2910
(Address) 15 3 to 0 Cc k r 1 00...)n 9-101 z5 — rya; 1 Se
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
(Address) 6030 CULLIGAN WAY
MIN JkpylcA, MN 55345 (City) (Zip Code)
(952) 933 -7200
(Contact Person) (Phone)
kl (a7 1 1 11
APPLICANT SIGNATURE DATE
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
— . ;'ost $ 3, 0O , 00 Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ yi .56
until June 30, 2013, STATE SURCHARGE $ S OD - .59 -
The minimum surcharge fora TOTAL PERMIT FEE $ _54. .SO
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 64 , Rece t Nob 4 16
Date (� (1 By
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