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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
ADDRESS
S~ Vt lo
C ( G ') S 0\ V\ ~ ( " Sty U t
Date Rec'd
1- /!;; oel
I Whi,e
2. Pink
J Yellow
File
City
Applicant
I PERMIT NO. 013.04-821
f (IvV L.q \L-~
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER" '
(Name) \...{) 'tL\
P-e~' s( hb"W
(Phone) q ':;'1 . t--j Y 1 ' l S-4 Y
(Address)
.BUfLIma eu V\rvt\.ctvy!. .
(CompanyName)~V\~(( ~tf{I()V<:'1 I L(
(Contact Name) l2m \ \\f UV\ ~x. t1v'\,
(Address) Po ~ U'f,.. 1I \P ~ I P t tD { l Ct \Lf ( ~l,- ~-l 1-
(Phone) q \' 1 - Lf lj () , I " t') 1
(Phone)
TYPE OF WORK 0 Nc:w Construction ODeck OPorch ~Re-ROOfing ORe-Siding OLower Level Finish 0 Fireplace
OAddition OAlteration OUtility Connection 0 Misc.
. CODE; OI.R.C. DI.B.c. PROJECT COST /V ALUE S J, OOO.uD
Type of Construction: I II ill IV V A B (excluding land)
Occupancy Group: A B E F H I M R S U
Division: 1 2 3 4 5
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-menltoned property and thatlU construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
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Si ature Contractor's License No. Date
Permit Valuation
Permit Fee S
Plan Check Fee $
State Surcharge $
Penalty $
Plumbing Pennit Fee $
Mechanical Permit Fee $
Sewer & Water Permit Fee $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
Buildin!! Ollicial
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 $ 7&. C/O
tNo. J-03s
ThIS is to certify thar the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutcs a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy. a Certificate of Occupancy must be
issued.
Planning Dirc.ctor
Date Special Conditions. if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372