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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
White
Pink
Yellow
File
CIty
Applicant
I PERMITNO.~-qO()
(Please type or print and sign at bottom)
ADDRESS
{l)d~;::?~ &J
/0 as;;;"
LEGAL DESCRIPTION (office use only)
ZONING (office use)
~tVd
LOT
BLOCK
/ ADDITION
OWNER
(Name)
r:~ ! ;~
(Phone)
t s-Z -- '-I t-j }- r2~Y
I..; t: ,,' )/1
~
(Address)
BUILDER
(Company Name)
(Contact Name)
(Address)
(Phone)
(Phone)
TYPE OF WORK 0 New Construction ODeck OPorch e-Roofmg ORe-Siding OLower Level Finish 0 Fireplace
OAddition o Alteration OUtility Connection
CODE: DI.R.c. DI.B.c.
Type of Construction:
Occupancy Group: A B
Division:
o Misc.
B
S U
A
R
5
IV V
I M
3 4
III
H
2
II
F
1
PROJECT COST IV ALUE
(excluding land)
I hereby certity that I have turmshed ml()rmation on this apphcation which is to the best of my knowledge true and conect. I also cerl1ly that I am the owner or authOrized agent for the
abc1Ve-mentlllned property and that all constructIOn will conform to all exisl1ng state and local laws and will proceed in accordance with submitted plans I am aware that the buildmg
official can revoke this 'rmil for Just cause Fu re, I hereby agree that the Clty official or a designee may enter upon the proper1y to perform needed mspecl10ns
7" /;,/Cl~
Date
I
E
x
Water Meter Size 5/8"; 1";
Pressure Reducer
Sewer/Water Connection Fee
Signature
Contractor's License No.
Permit Valuation
Park Support Fee
SAC
Permit Fee
$
$
$
$
$
$
$
$
TOTAL DUE
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Water Tower Fee
Builder's Deposit
Other
Sewer & Water Permit Fee
Gas Fireplace Permtt Fee
This Application Becomes Your Building Permit When Approved
BlIildlll~ Urticial
Date
$ ;;2 sCJD- --------
#
#
$
$
$
$
$
$
$
$
$ 7~ <
#
#
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 CIJl1Sl1tutes a temporary Certiticate of Zoning compliance and allows construction to commence. Before occupancy, a Cerl1ticatL' of Occupancy must be
Issued
Special Conditions, if any
Planning Director
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372