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City
Applicant
CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT ff <'1\<'1\ _ _ (\0 '"1. '"1.'"1CtCt 3 ~ ~
PermltNo.~
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
3. LEGAL DESCRIPTION
LOT \
1-:'A ;).C) ( c-V
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Hel~ (WIdIh) (DepIh)
12. NO. OF STORIES
O>S-~3S- -(b,-O
13. TYPE OF CONSTRUCTION
7. TYPE OF WORK
New Construction CJ
Chimney CJ Misc.
8. PROPERTY AREA OR ACRES 10. CULVERT SIZE
Sq. Ft Depth Yes No
I hereby certify that I have furnished information on this application which is to lhe best of my knowledge true and correct I also certify that I am 1he owner or authorized agent for
lhe abo mentioned a and all construction will conform to all existing state and local laWS and will proceed In accordance wl1h submitted plans. I am aware that 1he
buildi ffl aI can r Is It cause reo I hereby agree that 1he city ~ or a designee may enter upon 1he property to perform~ed Ins~' s.
~JIDO n 72_
~ No. DaI8
Heating CJ Plumbing CJ
Finish Attic CJ Residing CJ
14. FLOOR AREA APPORTIONMENT USE
Reroofing CJ Porch CJ
Finish Basement CJ
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Back
Side
Front
PROPOSED GRADE FOUNDATION
IN RELATION TO CURB OR CROWN
OF STREET
USE OF BUI ING
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
CIty:
Occupancy Group A BEl H R M
DMsion 1 2 3 4
7t.f,75
Permit Fee ..;................................ $
Plan Checking Fee ......................... $
State Surcharge ............................. $
Penalty ....................................... $
Septic System ............................... $
Olher .................... ............ ......... $
J, '2~
Check if
Dalerred
~~. 0-0
This
Idlng Permit When Approved.
Date rs: 2-1 ~ ~O
By
SIde
MATERIAL FILED WITH APPUCATlON
SOIL TESTS CJ ENERGY DATA CJ
PIUNG LOGS CJ PERCOLATION TESTS CJ
PlANS & SPECS CJ SETS
SURVEY CJ COPIES
PLOT PLAN 0
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
COllective Streat Fee ....................... $
SewerTap ................................... $
Ucense Check Fee ......................... $
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
CJ Sewer & Water Connection Fee ........... $
CJ Water Tower Fee ........................... $
Water Tap ................................... $
Olher ............................... .......... $
Other ;..................... ................... $
t> Total Due .............................. $
Paid otJ Recel No.
Date
This is to certify that the request in the above application and aooompanying documents Is In accordance with the CIty Zoning rdinance may
slgnsd By ths Cily Planner constitutes a temporary Certificate of Zoning compliance and a1101NS constnJctIon to commence. Before occupancy. aCe'
City Planner
DaI8 SpecIal Conditions If any
24 Hour notice for all inspections 447-4230 9:00 a.m. . 10:00 a.m.
The ('enler of Ihe Like Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT ~ }',\d.OX"S-. ~ ~tr:L1rs
APPLICATION RECEIVED ~ ~ ~.L.J tn) 8.ef7m
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
\f\CJ
.
38;;)0 L-i f\d(U) C----i r'cJL
Accepted
Accepted With Corrections :><-
Denied ~
Reviewed ~
Date:
6>2{-?&
Comments:
J. :r....\&. \.J..uv7 t~
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."