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CITY~OR LAKE BUILDING PERMIT,
TEMP~Y CERTIFICATE OF ZONING COMPLIANCE
~ AND UTILITY CONNECTION PERMIT
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LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
OWNER
(Name)
Date Rec' d
3, /9.01
I White
Pink
Yellow
I PERMIT NO. 07.
() 130 I
File
City
Applicant
ZONING (office use)
0/ f1/f:.
/1/. ;:
PID 2-5. Z~lR 050. ()
(Phone)
(Address)
I
i BUILDER
I (Company Name) c....tt4b t:.( ff . -S t ~)//J (p f /L-/:5-/Jt ,-,~/?-/,.z-<-.
I (Contact Name) - J I ''1.--7 -F/J/l-a/// bT-v
I (Address) I; (.-[/ H (;, /.-1- t./v'Dv/::/ fl/~
/ ('1-/ C.
(Phone) V I~ - 3br - 7 S J ,)'
(Phone)
/ _..c. Kd--.
TYPE OF WORK 0 New Construction ODeck OPorch ORe-Roofing
OAdditlOn OAlteration OUtility Connection
Re-Siding DLower Level FinIsh 0 FIreplace
CODE: DI.R.C. DI.B.c.
Type of Constnlction:
Occupancy Group: A B
Division:
I
E
II
F
I
III
H
2
IV
I
3
V
M
4
A
R
5
D Mise.
B
S U
PROJECT COST IV ALUE
(excluding land)
$
I hereby certity that I have hIrOlShed mforma .. n this applicatllll1 which IS to the best of my knowledge true and correct. I also certify that I am the owner \lI authollzed agent lur the
J~()V.~~oned propc.rty and. !~...co str tlOn will conform to all eXlstmg state and local laws and will proceed in accordance with submitted plans I am aware that .the tmildmg
OlljC".~evoke tillS perml )~t c I. Fu hermure, I hereby agree that the CIty official \lI a deSignee may enter upon the prope11y to perhorm needed mspec Ions
X ! \ "r/(. -. I ~'I )(~ _ __ / c . _ Ci:~)
/ Slg ture Cont ctor'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 $ I
This Application Becomes Your Building Pennit When Approved
Bulllhng OfliClal
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
ThiS lS to certify that the requl'st in the abllve application and accompanymg documents is in accordance With the City Zoning Ordinance Jnd may proceed as requested ThiS document
when signed by the City Planner cunsututcs a temporary Certificate of ZOI1mg compliance and alluws construction to cummcnce Before occupancy, a CertIficate of Occupancy must be
isslled
Planning Director
Special Conditions. if any
Date
2-t hour notice for all inspections (')52) ~~7-9!l50, fax (952) ~~7-~245
4646 Dakota Street Prior Lake, MN 55372