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pR1D Date Rec'd
" CITY OF PRIOR LAKE PLUMBING PERMIT
41I NNESO � P
191ue File PERMIT NO. / Q
3 Yel Ap / ✓ /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
513 t C GArl wOt.) N 1 a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) Kc ' 1 \ V 05k (Phone) 7 O 1 `� 1 ° � o� l
(Address) .513 BV (.,k W JO & _
APPLICANT
(Name) CULL!GAN WATER CONDITIONING-- (Phone)
6030 CULLIGAN WAY
(Address) MINNETPNKA, MN 55345
r ,� 2) 933 -7200 (City) (Zip Code)
(Contact Person) (l �� (Phone)
APPLICANT SIGNATURE DATE
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
Estimated Cost $ c DO.0 0 Building Permit #
PLUMBING PERMIT FEE $ Y , `a U
STATE SURCHARGE $ S = ■ O
TOTAL PERMIT FEE $ S `{ 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Rece o. 1035-
Date 5 ++ (J B
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372