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C ITY OF PRIOR LAKE PLUMBING PERMIT e../ 0 4 4N E s 0 -:" P:j I. Blue File
z. cold city PERMIT NO. 0 0087
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 4 a I G 14 v. w o.,r (r c,k 1 N v.] .5531 a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER --�-
(Name) --� N r) rn 0 (fl 3 k3 , c1 (Phone) 9 15 a - 4 y 7 - 5'7 IS
(Address) 3' a I G y w V �r a t I
APPLICANT (, ULi - W11 R C�3(�117I1` ON1NG
sil (Name) 6 030 CULLIGAN WAY (Phone)
MI MN 55345
(Address) (952) 9 33 -7200
(Address) (City) (Zip Code)
(Contact Person) Q (Phone)
APPLICANT SIGNATU 1 juui L 7 DATE - — S - 0
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 Softner
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (I 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 $39.50 minimum Residential, New One & Two - Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $ o100 . OD Building Permit #
PLUMBING PERMIT FEE $ L19 .50
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ St . b 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Pa 5O O Receipt No. 6 5 . 1 ��
Building Official _ Date 3, 5 O b By all
City of Prior Lake Bldg Dept.
24 hour not 4646 Dakota Street Southeast 7 - 4245
16200 . Prior Lake, Minnesota 55372 4
Phone: 952.447.9850
FAX: 952.447.4245
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