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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
41 ?'NESO
1. Blue File
z cola city PERMIT NO. /0 04,7
.
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
i 51 \T\ &_s 1.1 5537
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER LIZ (Name) 1 c `� C (Phone) - 3 - L3 0 3
(Address) N 15 1 \c.Q S rA1'\,, N W
APPLICANT UtJLLIUMN VVMI ch I.
(Name) 6030 CULLIGAN WAY (Phone)
(Address) MINNETONKA, MN 55345
(Adds ss1) 933 -7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE - ao - 10
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 j 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 $ act • 00 Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ 5. 0 0 —:38 --
TOTAL PERMIT FEE $ 5 0 5()
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 6 - 6 4 R pt No. &/ �
Date a 7. !3 B •
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