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oF rrt� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
�,`' � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �(, ZZ ���
� AND UTILITY CONNECTION PERMIT
U p
��'�'NESa�P I. White File
2. Pink City PERMIT NO . O O �
3 Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ZONING (ot� use)
1 y 1 y 3�� sh�e�r �Rt�e. . rv �., �
LEGAL DESCRIPTION (oflice use only)
LOT BLOCK ADDITION PID
�aWNER � '� � V '� � G.�� �C? (Phone) �O� � � �� `� '���9
(Address) �
BUII.,DER � � f� 1
(Company Name) Y1 fl � ��1� (Phone) � � � l� �"" � 7 ��
(Contact Name) � l.�J � � � �� �- (Phone)
(Address) �� � 11 �(`(� �S � �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re ❑Re ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection � p`�� 1 Q0.� �� OCJ'!� lA�� 1 n'�/7C 1 S'�1
� .��� � �'�M;�•
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc. — � �' ' '
Type of Construction: I II III IV V A B pROJECT COST/VALLTE $�; �� J
Occupancy Group: A B E F H I M R S U
Division; 1 2 3 4 5 (excluding land)
I hereby certify that I have turnished [nformation 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
abuve-mentioned p perty and that all construction wip conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can nevok his permit forjus se Furthermore, I hereby agree that the city o�cial or a designee may enrer upon the property to perform nec e mspections.
X �O ( 34 9 8`3 � �'/�UU /�
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $ �
This Applicatiott Becomes Your Building Permit When Approved Paid � Cel t NO. /
Date
Buildin � Otlicial D�te
Th�s is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requcsted. This document
when signed by the Ciry Ptanner consututes a temporary Certificate uf Zoning compliance and allows construction to commence. Before occupancy, a Certificau uf Occupancy must be
issued
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372