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CITY OF PRIOR LAKE PLUMBING PERMIT
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�. B�Ue file pERMIT NO.
z. �o�d �,Ty / L 10 �9
3. Yetbw Ar�ticant
1288C Ot � t 8IId � $t bOrt0111
ADDRESS ZONING (ot�'ice use}
Il�`t'1� Sa � Wa ss��
LEGAL DESCR�TION (oflPice usc onty)
LOT BLOCK ADDITION PID
OWNER -�
(Name) D 0 .`r1 'TI '�-1 � (Phone) � I a- g ��— 9 y�
(Address)
APPLICANT CUL�iCaAly WAT€Fi �U'.i�i�'FC�IVI�I�i (Phone)
{Name gp30 CULLIGAN WAY
(Address) MtNNETONKA MN 55345
(Add��) 933-7�00 (Ciry) (Zip Code)
(Conta.ct Person) (Phone)
APPLICANT SIGNATURE DATE 0' 3 0— I�
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain � Water Saftener
Lavato Bathraom 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
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family i% of job cost with a$49.50 minimum Residential, New One 8c Two-Farnily $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 st $ c���� � Building Permit #
" SURCHARGE " has been extended pLUMBING PERMIT FEE $ �9 �.5D
unril June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $ S, � 0 -59
"fixed fee" permit is $5,00 TOTAL PERMIT FEE $ - � S O
This Application Becomes Your Building Permit When Approved Paid �� /� Receipt No. 7 a ,/
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suua�ne o�tcia� nace Date l J �� -r By ,r.
24 hour noHce for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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