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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. God File PERMIT NO . -"
2. Yell App /3 _34
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
53 b Cr s sa n ..Y 4, S ss 3 - 7
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER —T 1 \
(Name) J G m u4 s L S� \,..1 �-W- (Phone) qs a - 5 5 - 5 a
(Address)
APPLICANT CULLIGAN WATER CONDITIONING
(Name) 6030 CULLIGAN WAY (Phone)
MINNETONKA, MN 55345
(Address) (952) 933 -7200
(Address) (City) (Zip Code)
(Contact Person) 1 (Phone) 9-1g-13
APPLICANT SIGNATURE _ _ _A , I 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 ( 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 $ A0O. 00 Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ '- .5
year effective STATE SURCHARGE $ .5 0 U -59
July 1, 2010, until .Tune 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 3
is b5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid i—. _ 31) Receipt No.‘ 6 f y
Date f /i / 3 By (../_--
Building Official Date `7`
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372