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47, pRl0 CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
�
' � % i � , �� TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
"`/ l �; ) `� �, 6,
AND UTILITY CONNECTION PERMIT
I. white File PERMIT NO . G
2. pink City a % . (J o 7 'Z
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 9 1 1 Card �'ta / K q e T
i' ro,_l "
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER . /
(Name) i t M S Lt.l l I YCCf (Phone) (75'd L/ 1` _ fU // Q
(Address) 5 Crd%/ / ' i t e /tai l
BUILDER /� G
(Company Name) (plc s `- Priem- l (» )a C l t (Phone) - b 3 5 �(i O 0 '-l3
(Contact Name) Cya r ,sIIL I ro p (Phone) i,5/ �W /d 9ggC/
(Address) 3566 0 ks ha v 1 Nj F y" 4 _4 m I 5-54 7
TYPE OF WORK Ne w Construction •l
❑ ['Deck ❑Porch ❑Re- Roofing - Siding DLower Level Finish ❑ Fireplace
['Addition ['Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B p � 7/
Occupancy Group: A B E F HI MR S U PROJECT COST/VALUE $ O Co S = 25
Division: 1 2 3 4 5 (excluding land)
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 building official can revoke ' pFrmit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed
inspectio . \ v\v
!1 x �� b7q3l 1 Coq
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 $ 76 , (/ o
This Application Becomes Your Building Permit When Paid G R e ✓ ipt No. 572. 6,, �- 7 Approved Tlatn 7
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