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OL D R _�
4 e CITY OF PRIOR LAKE PLUMBING PERMIT
H '
�/�'NES
2 Gold File .
2. Geld Ap PERMIT NO. / / �
3. Yellow Applicant ` [ ✓✓
(Please type or print and sign at bottom)
ADDRESS nn ZONING (office use)
L M5 NU S\ $ 553
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) � y g 0 ,r Kc\ (Phone) -SD 1- a'� 1 - .3SS 0
(Address) 1
APPLICANT CULLIGAN WATER CONDITIONING (Phone)
(Name) 0030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
'.� (Addre SZ) 933 (City) (Zip Code)
(Contact Person) • (Phone)
APPLICANT SIGNATURE (0"/ tJ DATE g _ a y -11
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 .i 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 $ .D 6 0 , 00 Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 49
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5.0 0 ..50
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ ,5'- . 5 0
is S5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 4_, R eipt N , rl
/i `, 1 1'
Buildine Official Date Date "� `'
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372