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, M Date Rec'd
9 CITY OF PRIOR LAKE PLUMBING PERMIT
v
4 r so
I. Blue File PERMIT NO . 9 '
2. Yell App licant i '1 i l 7
3. Yellow App �/
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I5a9y Oa v\1.5 C,r CI ss37�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) � GV \ 6 E\ - \' Q i (Phone) 70D. `-{ 3- 3 c j
(Address) 15a 'Ai __ 0Gki- C��
J
APPLICANT
(Name) (Phone)
CULLIGAN 11VAJ EH CONDITIONING.
(Address) 6030 CULLIGAN WAY
11(lAt+ ng ONKA, MN 55345 (City) (Zip Code)
(952) 933-7200
(Contact Person) .. (Phone)
APPLICANT SIGNATURE \ ` SI - ,, DATE Q - - -) 3
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 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
Estimated Cost $ ), 5 . 0v Building Permit #
The Minnesota Statutes § 326B.148 PLUMBING PERMIT FEE $ `1q • S0
"SURCHARGE" has been extended
until June 30, 2013, STATE SURCHARGE $ S. tD 0 - 50 --
The minimum surcharge for a TOTAL PERMIT FEE $ 54 , SO
"fixed fee" permit is $5.00
mg Permit When Approved Paid s- 7 � / � Receipt No. 4 icy
Date f i By ` �
Building Official Date a� /, .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372