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CITY OF PRIOR LAKE PLUMBING PERMIT Date Recd
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4 1 ,SQ' 2. Gold 1. Blue F ile I PERMIT NO. /Z /4
INNESD
3. Yellow Applicant
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS
j53 g � Cr C (1 e CO l..Yi 55
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER IN �Y L\, N 0.y r\ S O Y-‘ (Phone) 9 s a- a 3 - 03 0 1
(Name) 11
(Address) I S 3 g C r o`r\e- Cu I� A
APPLICANT (Phone)
(Name) CULLIGAN WATER CONDITIONING
6030 CULLIGAN WAY
(Address) MIN TON KA, MN 5-5345
g� 933 - 7200 (City) (Zip Code)
(Contact Person) (Phone)
L ... APPLICANT SIGNATURE I _ ... tte —DATE a - a3 - 1 .
APPLICANT PLEASE COMPLETE BELOW Type of Fixture
Quantity Type of Fixture Quantity yp
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
Backflow Assembly Test
Sinks Lawn Sprinkler
Bar Sink Other
Water Closet (Toilet)
FEE SCHEDULE
Industrial, Commercial & Multi- family 1% of job cost with a $49.50 minimum Residential, Additions ns & Alterations $49.50
:ost $ ,.- 00, 0 Building Permit #
The Minnesota Statutes § 326B.148 '19 5
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ C. 00
The minimum surcharge for a TOTAL PERMIT FEE $ . S 1 ‘ S 0
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid
Rec: o. 6Z4
Date i B
Building Official Date I
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372