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CITY OF PRIOR LAKE PLUMBING PERMIT
4-itivNEsos
1 Blue Cit P ERMIT NO. / / q /7 7
z. cola city /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
c.) 9.5 spKi K15 Lk. RS) 5s3
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER `` //
(Name) t) era( z i s kusk (Phone) q5Q - 44 D — L3 6.5
(Address) l
APPLICANT
(Name) CULLIGAN WATER CQNRITIQQ (Phone)
6030 CULLIGAN WAY
(Address) MINNFTfNKA, MN 55345
w.,.. (Addres�j952) 933_720 (City)
4 (Phone)
(Zip Code)
(Contact Person)
APPLICANT SIGNATURE DATE - 17 -
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
The Minnesota Statutes § 326B.148 ost $ ,D 00 , b� Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ V1.50
July 1, 2010, until June 30, 2011.
i t
TOTAL PERMIT FEE $ 7 U 5
The minimum surcharge fora' fixed fee perm STATE SURCHARGE $ , ��
is �5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid - Rec i t Nq.,, 4. O v
Date} By
Buildine Official Date q , 1(..f ( 1
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372