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CITY OF PRIOR LAKE PLUMBING PERMIT
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4 ' NNESO ,.P I. Blue File
2 Gold Cit PERMIT NCO.// /7
3. Yellow Applicant l
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
15 L'Cl V-rew\0rA N \,J 553
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Q C� � 95 - y > 09 I0
(Name) I") �'nn � e-. Z � e._ (Phone)
(Address) 1 5 L �' l r iei- , .- „, A..-L- N W
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
(Address) 0030 CULLIGAN WAY
MIKVi NKA, MN 55345 (City) (Zip Code)
` 52) 933 -7200
(Contact Person) (Phone)
APPLICANT SIGNATURE ,' 1 _ . DATE 3 ! ) - I 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 I 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
)st $ 1549 . O() Building Permit #
The Minnesota Statutes § 32613.148
"SURCHARGE” has been changed for one PLUMBING PERMIT FEE $ y 9 . SO
year effective STATE SURCHARGE $ 5, OQ
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 54,50
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 3-, / 3 Recie No. / j 7/
Building Official Date Date 3 36. ,11 B •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372