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!;)ATERECEIVED CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF
ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
1. White
2. Pink
3. Yellow
File
City
Applicant
Permit No.
{)e~ o1-7L
+lKt//eaJ ~
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
3. LEGAL DESCRIPTION
LOT
12. NO. OF STORIES
BLOCK
PID
13. TYPE OF CONSTRUCTION
ADDITION
14. FLOOR AREA APPORTIONMENT USE
9S-~-'f -~ 90
6. BUILDER (Name) (Address)
AIltt=IeIC4/fJ &lIbJ.J6f. C!.oN.,.~4crol!s ZC/(;;o'Vitd/dal et:fl
:S<<l'f~ 100
8'-'VIC/Sih
Deck 0
Finish Attic 0
(Tel. No.)
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
7. TYPE OF WORK
New Construction 0
Firepllace 0
Alterations 0
Septic 0
Addition 0
Porch 0
I ish Basement 0
SEATS
16. PROJECT COSTNALUE
tl . 'iJ'T
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
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
building offi ial can revoke th~erm,it for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inS~tiOns.
X .'.~ ~/bq3S37-/"-t) .
Signature license No. Date
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Fr,)nt
Back
Side
Side
MATERIAL FILED WITH APPLICATION
SOIL TESTS 0 ENERGY DATA 0
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
BUILDING DEPARTMENT VALUATION
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
SURVEY
PLOT PLAN
o COPIES
o
USE OF BUILDING
TYPE OF CONSTRUCTION: I II III IV V
Occupancy Group A B E F HIM R S U
Division 1 2 a 4
Permit Fee ................................... $
Cify:
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
Sewer Tap ................................... $
$
Plan Check Fee ............................. $
State Surcharge ............................. $
Penalty ....................................... $
Plumbing Permit Fee ....................... $
Mechanical Permit Fee ..................... $
Pressure Reducer .......................... $
Meter Horn................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
WaterTowerFee ........................... $
Water Tap ................................... $
Builder's Deposit......................... . $
Other ................................... ... $
Total Due ........................ ... . $
Paid ~. c/lJ Rec i No.
Sewer & Water Permit ...................... $
Gas Fireplace Permit ....................... $
This Application Becomes Your Building Permit When Approved.
By Date
Date
1G,~u/.)
.5l,.lz...
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 procee s requested. This document when
signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certific of Occupancy must be issued.
City Planner
Date
Special Conditions if any
24 hour notice for all inspections 447-9850