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Date Rec'd
c)• Y-11--1- O T
..; CITY OF PRIOR LAKE PLUMBING PERMIT
411 iv - NEso
I. Blue File
3 . Gold City PERMIT NO / / / O 2
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
33 3 1 Sk‘ 54 SE 553
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER n
(Name) y vN cLA \ l\ (Phone) L 1 - 9 2 - 99_5(5,
(Address) 3 \ $ kil r _s+ s:
APPLICANT CULLIGAN WATER CONDITIONING
(Phone)
6030 CULLIGAN VVAY
(Address) MINNETONKA, MN 55345
(Addrt P 933 7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE a - 3 - 11
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
The Minnesota Statutes § 326B.148 ;t $ cl0p ,00 Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ . 50
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ , S av -56
The minimum surcharge for a "fixed fee" permit
is , beginning July 1, 2010 TOTAL PERMIT FEE $ 5 .5 0
This Application Becomes Your Building Permit When Approved Paid 3L 5D Receipt . /_ z 72_.
Buildine Official Date By
By
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372