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CITY OF PRIOR LAKE PLUMBING PERMIT
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'NNESO
1. Blue File
2 Gold City PERMIT NO. C3 , 2_0 7
.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
07a Wct 3 ovl A nc n P CV - CA- 3S-3 -7 Q
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) — V ) Orl. 0 LTO r ' f (Phone) 6 1 a - - - 5 3 I - 90 5 0
(Address)
APPLICANT CULLIGAN WATER CONDITIONING
(Name) 6030 CULLIGAN WAY (Phone)
(Address) MINNETONKA, MN 55345
01;4933-7200 200 (City) (Zip Code)
(Contact Person) (Phone)
1
APPLICANT SIGNATURE ' ' 1 I DATE 3-3g-13
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
- - ost $ e) 1 49.0 6 Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ 1- }V5
until June 30, 2013, STATE SURCHARGE $ S . b 0 -49-
The minimum surcharge for a TOTAL PERMIT FEE $ , S 4 , .5 0
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 6 , - U Receipt Nc6 ( (/
Date /2- 2-. (3 By a
Buildine Official Date ti fi
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372