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CITY OF PRIOR LAKE PLUMBING PERMIT
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I.sole File
2.Gold City PERMIT NO./5-:
(RA
R 61
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
1ssy I m cL-d1 C fc-LL 553 "1ck R/S.C�
LEGAL DESCRIPTION(office use only)
b - eeK ION PID Oq✓" d —o/Q-0
OWNE(Name) J ' 5 L" (Phone) 1) 1 ) - ab9- 3 1 dy
me
(Address)
APPLICANT
(Name) CULLIGAN WATER CONDITIONIN(- (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN_ 55:145
(Address) (952) 933-7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE b-30 -LS
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 $ Building Permit#
PLUMBING PERMIT FEE $ y�
STATE SURCHARGE $
• TOTAL PERMIT FEE $
(Office Use Only) '9+ Sd
This Application Becomes Your Building Permit When Approved if Receipt No.
i at- By
Building Official Date + /
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372