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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please
ADDRESS
5()'3 Jf:'fClJ./Cr L-IIICe- RC5A-b
at bottom)
Date Rec' d
8. /0.00
White
Pink
Yellow
File
City
Applicant
I PERMIT NO. 0(;. 0 7/1
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID25,1S4-. 01 I. ()
OWNER
(Name)
/11/t!#H&C- tf eie,.,-ek:-
..,...-;~ 1/ V LIJ~E
(Address)
(Phone)
t:{.52 -1fe>-4-9~
I BUILDER
I (Company Name)
I (Contact Name)
I (Address)
() fLrAlt?/L
(Phone)
(Phone)
TYPE OF WORK 0 New Construction
DAddition DAlteration
DLower Level Finish 0 Fireplace
CODE: DI.R.C. DI.B.c.
Type of Construction:
Occupancy Group: A B
Division:
I
E
II
F
I
III
H
2
IV
I
3
V
M
4
o Misc.
A
R
5
B
S
PROJECT COST IV ALUE
(excluding land)
$
U
I hereby certify that I have hlrmshed mf()rmation 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 f,n the
above-mentIOned properry and that all cunstruction WIll conform to all eXlstmg state and local laws and will proceed in accordance with submitted plans I am aware that the buildmg
official can revoke thIS perml! for Just ermo ,I hereby agree that the Clry official or a desIgnee may enter upon the propelty to perform needed mspectIOns
x
Signature
Permit Valuation
Z. 500.60
Permit Fee
$
$
$
$
$
$
$
$
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
Gas Fireplace PermIt Fee
Contractor's License No.
/t) .liVe;- t10
Date
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 $ 7&.00
Paid
Date
J,-fri :t~
I
I ~;ceiPtNo'4L{5
ThiS IS to certIfy that the request 10 the above applicatIOn and accompanymg documents is in accordance with the City Zoning Ordinance and may proceed as requested TIllS document
when signed by the CIty Planner cunsl1tute:; a temporary Certificate of Zonmg compliance and allows constructIOn to commence Before occupancy, a Certificate of Occupancy must be
Issued
Planning Director
Special Conditions. if any
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372