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0 CITY OF PRIOR LAKE PLUMBING PERMIT
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.''�Nzsoo I. Blue F
z. Gold C ity PERMIT NO. / 347‘5L
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
390 S ote"\ PI Qc_t_ ■J 553 7 a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ) 0,_■)' Ge- \ { ks, (Phone) 61D- -/ ki 3 - - 7t)
(Address)
APPLICANTULLfGAN WATER CONDITIONING
(Name) 6.030 CULLIGAN WAY (Phone)
iMINNETONKA, MN 55345
(Address)
d e�sy�`I' /200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE �,1 _ II N DATE r ] - 3 - 3
/
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 I 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 I% 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
"SURCHARGE" has been extended >t $ a DO . Building Permit #
The minimum surcharge for a
"fixed fee" permit is $5.00 PLUMBING PERMIT FEE $ ticj .50
STATE SURCHARGE $ -5;b 0 -
TOTAL PERMIT FEE $ ,...59.56
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid f Receipt No. } G l 7
Building Official Date Date ,, 7 /� ? B
24 hour notice for all inspections (952) 447 -9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372