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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please
ADDRESS
Date Rec' d
e. .10. ~6
I White
Pink
'\ Yellow
File
City
Applicant
0(,.0
PERMIT NO.
WrlY
L/"1 .IV e R/tI' &) e;,
ZONING (office use)
118;
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
OWNER
(Name)
(Address)
BUILDER cJ
(Company Name) t:1J1:Jr<.
(Contact Name) C-I-IIID 0"
(Address) Zl.{Lf - ~h
Ct2l c..k.J..(J j.\J
JUW
P ID z5..
~. PSJ.O
(Phone)
~1. z...f1./1Z0
e..., ~ I'll Pit" or ~J~
(Phone) Pbs}"?S?- 3<(69
(Phone)
TYPE OF WORK 0 New Construction ODeck OPorch ORe-Roofing ORe-Siding OLower Level Finish 0 Fireplace
DAddition OAlteration OUtility ConnectIOn
CODE: DI.R.c. DI.B.c. )( Mise /" L,HWA/ 1/i!.Je.,/ qR77 () Ai
/'I6-€~
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 certiJY that I have hlrmshed 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 tor the
dbove-mentlOned property and that all construction wIll conform 10 all eXIstIng state and local laws and WIll proceed in accordance with submmed plans I am aware that the buIldIng
official can revoke thIS permll for Just cause Furthcrmore, I hereby agree that the CIty nfficial or a deSIgnee may enter upon the propeny to perform needed 1I1spectHlns
x
Signature
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
Penalty $
Plumbing Permit Fee $ 4-0.00
Mechanical Permit Fee $
Sewer & Water Permit Fee I $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
l3uilctlll!! OHlcial
Date
Contractor's License No. Date
t Puk S"ppon Fee # $
SAC # $
Water Meter SIze 5/8' I'" $
,
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
TOTAL DUE :b
ThiS IS to certify that the request m the above applicatIOn and accompanymg documents is in accordance with the City Zoning Ordmance and may proceed as requested ThIS document
when signed by the City Planner constllutes a temporary Certificate of Zonll1g 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