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PATE RECEIVED
CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF
ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
I. White
2. Pink
3. Yellow
File
City
Applicant
Permit No.
08. oZ(p 1
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
, .[1
1. DATE
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
3. LEGAL DESCRIPTION
LOT
ADDITION
~ ;'
12. NO. OF STORIES
BLOCK
PID
13. TYPE OF CONSTRUCTION
14. FLOOR AREA APPORTIONMENT USE
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
SEATS
New Construction 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq.Ft.
Finish Attic 0
Finish Basement 0
9. PROPERTY DIMENSIONS
Width Depth
10. CULVERT SIZE
Yes No
I hereby certify that I have furnished 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
the above mentioned 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
bu" official can revok is ermit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform need inspecti ns.
if/' -'-r)
X ~~_
License No.' Date
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Front
Back
Side
Side
MATERIAL FILED WITH APPLICATION
SOIL TESTS 0 ENERGY DATA 0
BUILDING DEPARTMENT VALUATION
OFF STREET PARKING
SPACES REa.
SPACES ON PLAN
PERMIT VALUATION
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
USE OF BUILDING
SURVEY
o COPIES
PLOT PLAN
o
TYPE OF CONSTRUCTION: I II III IV
Occupancy Group A B E F HIM
Division 1 2 3 4
Permit Fee ................................... $
V
R S U
City:
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
Sewer Tap ................................... $
$
Plan Check Fee ............................. $
State Surcharge............................. $
Penalty....................................... $
Plumbing Permit Fee ....................... $
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
Water Tower Fee ........................... $
Water Tap ................................... $
Builder's Deposit ............................ $
Other ......................................... $
Total Due ............................ $
Paid 7(, - Rec'
Date .5"'.. ~ (,
MeChanical Permit Fee ..................... $
Sewer & Water Permit ...................... $
Gas Fireplace Permit ....................... $
This Application Becomes Your Building Permit When Approved.
By Date
City Planner
Date
Special Conditions d any
'1(P 0 0
E;s-}+-
Certificate of Occupancy
Issued
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proc
signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certi c
24 hour notice for all inspections 447-9850