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04 4Rf04 Date Recd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. B{ue File
PERMIT NO.
z. cola City /3 lL /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
19 al I ■0O1 Q.,4 Cf S Ss37
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) OWNER Ch ns4 ct (Phone) 61Q T-17 -c) 2 L5
(Address)
APPLICANT CULLIGAN WATER CONDITIONING (Phone)
(Name) 6030 CULLIGAN WAY
(Address) MINNETONKA, MN 55345
(Adifik0 933 -7200 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 10 1 6 -
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
The Minnesota Statutes § 3268.148 FEE SCHEDULE
of 'ob cost with a $49.50 minimum Residential, New One & Two - Family $149.50
"SURCHARGE" has been extended Residential, Additions & Alterations $49.50
The minimum surcharge for a
"fixed fee" permit is $5.00 a $ Q00. b6 Building Permit #
PLUMBING PERMIT FEE $ y9.Sb
STATE SURCHARGE $ .S 0 D
TOTAL PERMIT FEE $ - 5 - 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid -4/ 3 7J Receipt No. w J 4? _
Building official Date Date /DAL 9/' By 4
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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