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e CITY OF PRIOR LAKE PLUMBING PERMIT 4—, 5: //
jNNEsdit 1. Blue File
2. cold city PERMIT NO. ii . 1 7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I` f ookyn ex _ ., \v n■.l
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N R \\ 0 W (Phone) L L a` 8 I L- 0 9
(Address) \ 3 L 3 e r 0 u \._ l`t_s A G\ U
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNFTC14KA, MN 55345
(Ad4r) 933-7200 (City) (Zip Code)
(Contact Person) (Phone)
(� )
APPLICANT SIGNATURE _ ...9, w-' DATE 2 - ay
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 $ ( D001 0 V Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ 9 , 5 0
year effective STATE SURCHARGE $ -59- 5 0 0
July 1, 2010, until Jane 30, 2011.
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 51 , 5 ()
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5i; 5 7 ) Rec /t No. / 9
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Date B U/
Buildine Official Date �' ' �� • /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372