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° CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue Ftl PERMIT NO.
2. Geld A /3 z_0(
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
`�l alb EQuC1a\rt_ " 14.1l I 5537
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER QQ
(Name) Cho i' l� 5 3 551 er (Phone) Lt a L 3g 7753
(Address)
APPLICANT
(Name) CULLIGAN CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
0 (4 1 32 3 093 3 - 72 00 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE tql 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 $ 600. 0t Building Permit #
PLUMBING PERMIT FEE $ . S�
STATE SURCHARGE $ c. 00 $6
TOTAL PERMIT FEE $ , 54.56
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid L 5 - Rec ' t No. , U a C�
Date 4 ` e l l /3 B
Building Official Date "T
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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