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CITY OF PRIOR LAKE PLUMBING PERMIT
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44 NNESDo* 1. ue F PERMIT NO. /2 S0
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I too '13 70,1-N ■ „-,.kq PI acA —5_537D,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Naam CC cx y D' c Tl r (Phone) (DID,- 7 Oa - a 9 L 7
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(Address) I O oV■rka P ■ CLC
APPLI
(Name) CANT CULLIGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
(Add s ?) 933 -7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 1 - 5 - 1 __14
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
G q Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326R148
ost $ 1 Q 9 1. 0 0 Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ y9. Su
The minimum surcharge for a STATE SURCHARGE $ .S o0 -50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ . 50
This Application Becomes Your Building Permit When Approved Paid a�`/, j _ R ■ pt No. 41 �/ G
Date 4 / sr , I
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