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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
q--Ih-'OZ-
1_ White File
2 Pink City
3 Yel10w Applicant
PERMIT NO.02- - / I b1
ADDRESS
173~Y
Up$/2r;e/c!Or-
LEGAL DESCRIPTION (office use only)
LOT
5~
PID2~...372 -tl~....O
ADDITION
ZONING (office use)
t!-,
OWNER
(Name)
(Phone)
? -r;?- 9'~7. ~..l?C.
'"S /~
(Address)
hi S~/E6"./
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BUILDER
(Name)
(Contact Name)
(Address)
(Phone)
(Phone)
TYPE OF WORK
o New Construction
~Deck
OPorch
ORe-Roofing
ORe-Siding
OLower Level Finish
o Fireplace
OAddition
OAlteration
o Misc.
PROJECT COST IV ALUE (excluding land) $
OUtility Connection
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and cortect. 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 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 rty to perform n d inspe . ns.
x
City SAC and WAC
Water Tower Fee
#
#
Signature
Contractor's License No.
Park Support Fee
SAC
#
#
Permit Valuation
Permit Fee
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
$
$
$
$
$
$
$
$
"
Water Meter Size 5/8"; 1";
Pressure Reducer
Builder's Deposit
Other
TOTAL DUE
Date
$
$
$
$
$
$
$
$
$
\ Paid "(1-cot
Date 1/fr../t -
Receipt No':JOf7
By H
This is to certifY that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director
Date Special Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
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