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CITY OF PRIOR LAKE PLUMBING PERMIT
F �
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'. g'ue F"` pERMIT NO. p
2. Gold City �� � X��
3. Yellow Applicant V
E88t OL L 8IId S 8t I10fYOM
ADDRESS ZONIlVG �ot�ce ,�>
y:� a� Pa�-Ics ;��. c� N�,J ss3 ��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER V , n
(1Vame) 1`� r� � 1"a,n� c� (Phone) 6 �a - g a� ` O�0 3
(Address) �� 3� V"o. ✓`(,.S i N W
APPLICANT '
�� CULLIGAN WATER CONDITIpN�(�r� (Phone)
'6030 CULLtGAN WAY
(Address) MlNNETONKA,�N 5�3�5 �
(A�� 933-7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 7' ��l "� a
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fizture uanH T e of Fia�ture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain � Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bax Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercia( & Mutti-famiiy 1% of job cost with a$44.50 minimum Residential, New One & Two-Family $149.50
Residentiai, Additions & Alterations $49.50
st $ 0��0. d(� Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended pLUMBING PERMIT FEE $ 49,SD
until June 30, 2013, STATE SURCHARGE $ S. OU -�59�
The minimum surcharge for a TOTAL PERMIT FEE $ S4� SQ
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit W6en Approved Paid � � Receipt No. '
Da y
Baitdina Official Date � , ( �
24 hour aotice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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