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CITY OF PRIOR LAKE PLUMBING PERMIT
V
1. Blue File PERMIT NO
2. Gold NO. �
y f 743
3. Yellow Applicant
Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
)4-35a Pc - C4 Nom) 553 70
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER --�
(Name) l YvN V \ ti e >nc-k (Phone) L 1 - bl (, - / 13 (o
(Address)
APPLICANT (JIJLL!UAN WATER CONDITIONING
(Name) 6030 CULLIGAN WAY (Phone)
MINNETONKA, MN 55345
(Address) (952) 933 -7200
(Address) (City) (Zip Code)
(Contact Person) (Phone)
1 i
APPLICANT SIGNATURE S MOIL _ DATE - a() - L3
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
Estimated Cost $ 000 . Q 0 Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ Sy . So
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 1 Receipt No. n e
Date By
i 3 By 4 1
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