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CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF
ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
DATE RECEIVED
3. g.o(P
DIRECTIONS
SPACES NUMBERED 1 THRU 17' MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
~;).. 7 3 S(L.rn S' f.
3. LEGAL DESCRIPTION
LOT
BLOCK
PID
ADDITION
1. White
2. Pink
3. Yellow
File
City
Applicant
Permit No.
ora. 00 I 0
1. DATE
3 -tv -o(p
iJr~
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
12. NO. OF STORIES
13. TYPE OF CONSTRUCTION
'[/1
14. FLOOR AREA APPORTIONMENT USE
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
SEATS
16. PROJECT COSTNALUE
$ K': U
17. CO LETION DATE
6-- ()
r.
Re.roofing 0 Porch
Re-siding ~inish Basement 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq.Ft.
9. PROPERTY DIMENSIONS
Width Depth
10. CULVERT SIZE
Yes No
I hereby certify that I have fumished 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
. d 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
n r~oke this it"jUst cause. Furthermore, I hereby agree that the ci!}' official or a designee may enter upon the property to perform needed inspectic;rs.
X ,,2/73 '3 -~ _ () ~
Signature License No. Date
SETBACKS: Required
Actual
FOR ADMINISTRATIVE USE
MATERIAL FILED WITH APPLICATION
Front
Back
Side
BUILDING DEPARTMENT VALUATION
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
USE OF BUILDING
TYPE OF CONSTRUCTION: I II III IV V
City:
Occupancy Group A B E F H IRS U
Division 1 2 3 4
Permit Fee ................................... $
Plan Checking Fee ......................... $
State Surcharge ............................. $
Penalty ....................................... $
Septic System ........................."'.... $
Other ....................................".... $
Subtotal............................... $
This Application Becomes Your Building Permit When Approved.
By
Date
Certificate of Occupancy
Issued
Side
SOIL TESTS
o
o ENERGY DATA
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
SURVEY
PLOT PLAN
o COPIES
o
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
Sewer Tap ................................... $
License Check Fee ......................... $
Pressure Reducer .......................... $
Meter Hom ................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
Water Tower Fee ........................... $
WaterTap ................................... $
Builder's Deposit ............................ $
Other ......................................... $
Total Due .............................. $
Paid (,. 0 0
Date ::!. S, db B
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 requested. This document when
signed by the City Planner constitutes a ttlmporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued.
city Planner
Date
24 hour notice for all inspections 447-4230
Special Conditions ff any