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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
3, 1'7: of
I White
Pink
Yellow
File
City
Applicant
PERMIT NO. ()t. () II 0
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
(Name)
(Phone)
(Address)
BUILDER
(Company Name)
(Contact Name)
I.. -1J~OMle~
(/
~u-<e ~odetJ~,
/3
(Address)
5 '/0
uJ eg/
/j t-Wt'f,tfl/; ~
(Phone) ~~,t - 0':7'0/ - i600
(Phone)
JJ ~S'33 7-
TYPE OF WORK 0 New Construction ODeck OPorch ORe-Roofing
OAdditlon OAlteration OUtility ConnectIon
e-Siding OLower Level Finish 0 Fireplace
CODE: DI.R.c. DI.B.c. o Misc.
Type of Construction: I II III IV V A B PROJECT COST IV ALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: I 2 3 4 5
I hereby certity that 1 have h.rmshed mfmmatwn on this applicatIOn which IS to the best of my knowledge true and correct. I also certify that I am the owner or authol1zed agent tlJr the
Jbovc-mentwned property and that all constructIOn will contl,rm to all eXIstmg state and local laws and will proceed 10 accordance with submitted plans I am aware that the build 109
oftlcia! can revoke tillS permIt f[)f Just cause Furthermore, I hereby agree that the CIty official or a deSIgnee may enter upon the propelty to pertllrm needcd mspcctl\lnS
X /ta/04.trf ~~ 1/, .3 hp /0((
Signature Contractor's License No. . Date
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
I Penalty $
I Plumbing Permit Fee $
Mechanical Permit Fee $
Sewer & Water Permit Fee I $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
Bulldmg Uflicial
Dat~
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; I"; $
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
TOTAL DUE $
ThiS IS to certify that the request in the ab()VL' applicatiOn and accompanY1l1g documents is in accordance with the City Zoning Ordinance and may procecd as requested. TillS document
when signed by the City Planner constItutes a temporal)' Certificate of Zonlllg complIance and allows constructIOn to commence. Before occupancy, a Certificate of Occupancy mllst be
isslled
Planning Director
Special Conditions, if any
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372