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o* PR /p� CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
,� TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
U frj
* jNN E SO t' I. white File PERMIT NO .
3 pelf Applicant
// /81 3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / k ZONING (office use)
j `�� I CP 7 I �tn ��c( Ai
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID 2 0 /. Q o Z
OWN t 14(11 .e1r !f (Phone) QE To q0>
(Address) _3t: 1VQ Umkea l ,ita( Qd ill 0 SS 9 9
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( Nam- 0 t Sns (OfS ` 0 C,/ (Phone)QSZ4b9 ‘D
(Contact e�(� t# / r r , ' (Phone) qS)- p S �-„-
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TYPE OF WORK ❑ New Construction ['Deck ❑Porch ❑Re- Roofing e-Siding ['Lower Level Finish ❑ Fireplace
❑Addition DAlteration ['Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc. ,� �,/�
Type of Construction: I II III IV V A B PROJECT COST /VALUE $ L / / ��CJ
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
1 hereby certi ` that I ve furnished 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
above -memo ed pro ,erty and of tion will conform to all existing state and local laws and will proceed in accordance with submitted plans. 1 am aware that the building
re o1 s i it ffs . se. Furthermore, 1 hereby agree that the city o or a designe may enter upon . e pi operty to perform necd�
r tnspectit // v.
' isr�� C O,
�o'Si Contractor's License No. Date
Permit V.luation 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 $ 79. 7__(
This Application Becomes Your Building Permit When Approved Paid SIMMIIMIIM Recei s t No. A r'
Date MEMNIMIMI B Ally .11
/
Building Official Date
This 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 requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of 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