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"1) CITY
Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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ot. � r AO 9
��NES � L Blue File PERM730
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2.GoldlApp • I�3.Yellow Applicant � IT(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
01I R0�Lt1\ S4 Ni S53 ? IR./ SZ
LEGAL DESCRIPTION(office use only) /
LOT / BLOCK Z ADDITION 4/41e7P-S Z NA A-0,6/0 PID R -,3 ) b,'Q
OWNER V
(Name) \c c5‘Q V\e` (Phone) 6I . -5 R t - 3S? S
(Address)
APPLICANT
(Name) CULLIGAN WATER CONDITIONING (Phone)
(Address) 6030 CULLIGAN WAY
A
( ddress NKA, MN 55345 (City) (Zip Code)
52) 933-7200
(Contact Person) (Phone)
Q
APPLICANT SIGNATURE L� DATE cis -_3 - 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 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 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 $ Li? eco
STATE SURCHARGE $ I IAD
TOTAL PERMIT FEE $ S0 . SU
(Office Use Only)
ciThis Application Becomes Your Building Permit When Approved E' •.h• 50 0 Receipt Noll g1
•ateV, r s/ By
Buildinc Official Date f i I
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372