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CITY OF PRIOR LAKE PLUMBING PERMIT ri. + 2 , ( I
NNNESOo I. Blue File
2. Gold City PERMIT NO. `/ /3z7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 1 03 t c. ; ti l n Li SS 37a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1-
(Name) C WY -A ■ 5 -r� U Y 0 n (Phone) 6l a - g95- '7 a g
(Address) 3 b3 r() NA 7 G(1) — TI C . I I
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
(Addri 2) 933-7200 (City) (Zip Code)
(Contact Person) (Phone)
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APPLICANT SIGNATURE DATE 1 a -1- 1I
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 ,ost $ a(rJ• U� Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ L19.51)
until June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $ S o0 :5$
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ Sy .50
This Application Becomes Your Building Permit When Approved Paid 14 Da te :eipt 1(� Ncto I / Io c
Building Official Date ' Z' t2,11 •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372