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DATE RECEIVED
/0. 25.0~
CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF
ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
1. White
2. Pink
3. Yellow
File
City
Applicant
I;; / 05
Permit No.
O/j-'lot3
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
1. DATE
-05'
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
12. NO. OF STORIES
LOT
BLOCK
PID Z,<). 17 7~. () 3'0 . 0
13. TYPE OF CONSTRUCTION
ADDITION
4. OWNER
(Name)
(Address)
({ 5Jl)
14. FLOOR AREA APPORTIONMENT USE
~
5. ARCHITECT
(Name)
(Address)
8ud f- ~x-kYltJ(S
(Address)
~ D 11 I~ j cDl' tt ,A...o.e
(Tel. No.)
IZ\' '. I. q~2-~ 1-ILPI~
u tlCCl'\.l V\.l)ttr\ (j I ~ f)
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
6. BUILDER (Name)
7. TYPE F WORK
New Construction 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq. Ft.
Fireplace 0
Alterations 0
Septic 0
Addition 0
Deck 0
Finish Attic 0
Re-roofing
Re-siding 0
SEATS
16. PROJEC,J"CPSTNALUE
"0 'rOO tJ ()
17. COMPLETION DATE
9. PROPERTY DIMENSIONS
Width Depth
1 O. CULVERT SIZE
Yes No
I hereby certify that I have fumished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for
the above mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the
building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X & .<1.AA'L.- rY1~ (p ~t.P4 I 0-1"-1 - 0 ::5
~ License No. Date
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
MATERIAL FILED WITH APPLICATION
Front
Back
Side
Side
SOIL TESTS
o ENERGY DATA
o
USE OF BUILDING
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
BUILDING DEPARTMENT VALUATION
SURVEY
PLOT PLAN
o COPIES
o
TYPE OF CONSTRUCTION: I II III IV
Occupancy Group A B E F HIM
Division 1 2 3 4
Permit Fee ................................... $
V
R S U
City:
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
Sewer Tap ................................... $
$
Plan Check Fee ............................. $
State Surcharge ............................. $
Penalty....................................... $
Plumbing Permit Fee ....................... $
Gas Fireplace Permit ....................... $
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
Water Tower Fee ........................... $
Water Tap ................................... $
Builder's Deposit ............................ $
Other......................................... $
Mechanical Permit Fee ..................... $
Sewer & Water Permit ...................... $
This Application Becomes Your Building Permit When Approved.
By Date
Certificate of Occupancy
Issued
Paid ' (; ...--
Date /0. z.l < j'-
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may pr ee
signed by the City Planner const~utes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy. a Ce ifi
C~y Pianner
Date
Special Conditions ~ any
24 hour notice for all inspections 447-4230