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DATE RECEIVED CITY OF PRIOR LAKE
/ / ~ + - () 2- BUILDING PERMIT,
TEMPORARY CERTIFICATE OF
ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
1. White
2. Pink
3. Yellow
File
City
Applicant
Permit No.
()2.-j45B
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
1. DATE
tj{ -
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
3. LEGAL DESCRIPTION
12. NO. OF STORIES
LOT
BLOCK
PID
<.JL
(Tel. No.)
qSJ.-
(Tel. No.)
13. TYPE OF CO
re...-(a re-
14. FLOOR AREA APPORTIONMENT USE
ADDITION
(Address)
c)
(Address)
6. BUILDER
~t..C.e(
(Name)
N\e..c.\. oC: C'f\o~"\.\f'''''~
C1.,3oc
Septic
Addition 0
(Address)
q (Tel. No.)
SJ-1i'81-,J'"Jo 7
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
New Construction 0
Fireplace 0
Alterations 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq. Ft.
9. PROPERTY DIMENSIONS
Width Depth
1 O. CULVERT SIZE
Yes No
SEATS
16. PROJECT COSTNALUE
I 0 {) l"Jf-
17. COMPLE ON DATE
L~ - 3 i - 0;)..
7. TYPE OF WORK
I hereby certify that I have furnished 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 tioned property 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 0 an revok this or t cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X 1\-0&- O,~
License No.
Date
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Front
Back
Side
Side
MATERIAL FILED WITH APPLICATION
SOIL TESTS 0 ENERGY DATA 0
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
BUILDING DEPARTMENT VALUATION
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
SURVEY
'/U PLOT PLAN
o COPIES
o
USE OF BUILDING
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 ....................... $
SewerTap ................................... $
$
Plan Check Fee............................. $
,4.75-
,-
J. z, r-
State Surcharge ............................. $
Penalty ....................................... $
Plumbing Permit Fee ....................... $
Pressure Reducer .......................... $
Meter Horn................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
Water Tower Fee ........................... $
Water Tap ................................... $
Builder's Deposit ............................ $
Other ......................................... $
Paid TotalZ~ (/tT..........~~~~i~;.. $
Dale J 1,4 ....O'Z- By
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proce
signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certific
.................. $
Mechanical Permit Fee ..................... $
Sewer & Water Permit ...................... $
Building ;:tr::'':j] ~Plrr~,---,
Certificate of Occupancy
Issued
Crty Planner
Date
Special Conditions IT any
24 hour notice for all inspections 447-9850