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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
q- /(,--02-
White File I PERMIT NO
Pink City . "'I 7~ / ! I {; ! .
Yel\ow Applicant , J -- \..R
1~.s2 3
/-JA/JV /jv6
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID Z. -:;..- (JOZ- - 66:? - U
I OWNER
(N ame)
(Address)
(Phone)
BUILDER
(Name)
(Contact Name)
(Address)
J~<Jh }(; \, "1\ .~'- ~,
~ h''v' c.-
(Phone)
(Phone)
{'l)--'JJ If" 31. {. Y
TYPE OF WORK
o New Construction
ODeck
OPorch
ORe-Siding
OLower Level Finish
o Fireplace
o Addition
Re-Roofing
OAlteration
o Misc.
PROJECT COST IV ALUE (excluding land) $
DUtility Connection
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-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
Water Meter Size 5/8"; 1";
Pressure Reducer
Signature
Contractor's License No.
Permit Valuation
Permit Fee
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
Gas Fireplace Permit Fee
C-,
Park Support Fee
SAC
#
#
$
$
$
$
$
$
$
$
--
,. L r
#
#
City SAC and WAC
Water Tower Fee
Builder's Deposit
Other
TOTAL DUE
'- c.-,.) -
$
$
$
$
$
$
$
$
$ 7fcp'O
This Application Becomes Your Building Permit When Approved
Building Official
Date
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