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CITY OF PRIOR LAKE PLUMBING PERMIT
41 4 , NEsdo
1. Blue File
z cola city PERMIT NO. ` ( ( I 4 .3
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
15 1 � 0■1 ( 6Or P N E . 5537 )
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) C \ \LY (\eW yv n (Phone) L ( 3810 - c7S") u
(Address) L5O4 N CSI bv✓ i"l( C.12 IV-f
APPLICANT
(Name) CUL I IGAN WATER CONDITIONING (Phone)
6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
( 5J33 - 7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE ( - S- (
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 1 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
^ ° * °a Cost $ p 1C0. U Building Permit #
The Minnesota Statutes § 3268.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ uct , 5D
until June 30, 2013, STATE SURCHARGE $ $ °D --
The minimum surcharge for a TOTAL PERMIT FEE $ 54. 5b
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid Sy Rece No.
Building Official Date Date iO 1 � B
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372