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Date Rec'd
,� 4 CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City PERMIT NO . /' 7
. 1(/
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
_33 9 1 Sp r'i n5 G Irv, C∎ ( c-1 553'2 e ) \
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER to 3 ` I (Phone) S 1 -sou - 3 S (Name) C I h ��� � S V Av e k L
(Address) .3391 � r` j Glev- CI YC.\e
APPLICANT J
(Name) CULLIGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) (Ad MMI ess NETONKA, MN 55345
(City) (Zip Code)
ct� 952) 933 -7200
(Contact Person) (Phone)
APPLICANT SIGNATURE
al Kai L = - DATE - a - I
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
The Minn ota Stat s § 326B.148 )st $ Building Permit #
"SURCHARG ' a een changed for one
ye ffective PLUMBING PERMIT FEE $
July 1, 201 un June 30, 2011. STATE SURCHARGE $ .50
The minimum charge f a "fixed fee" permit TOTAL PERMIT FEE $
is is beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 5 - 0 Re ipt Not e 3 z w
Date /
Building Official Date . / I -
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372