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Oti f Pli CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
v AND UTILITY CONNECTION PERMIT
kiNNE I. White File PERMIT NO .
3 pink Cp li I
(Please
3 Yellow Applicant `
( type or print and sign at bottom)
ADDRESS ZONING (office use)
3S - IC 6Z VAii,c /2 e0
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ..
(Name) ( 4 L _ I t' / i ar . y f f • (Phone) l 5 .2 - V1 I 0 4 60
(Address) 4).._ C et.�� // ,n' k N • C m ,etc ri s a V 3
BUILDER
(Company Name)_ (Phone)
(Contact Name) _ ,'i 1 1 "(N (Phone) j Ifa - 4 bs 041
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re- Roofing DRe-Siding ['Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection /�
CODE: ❑I.R.C. ❑I.B.C. isc. � 1Z /li (..&oeJ /17 V 4-t
Type of Construction: I II HI IV V AB V
Occupancy Group: A B E F HI MR S U PROJECT COST /VALUE $
Division: 1 2 3 4 5 (excluding land)
I hereby certify that 1 have furnished information on this application which is to the best of my knowledge true and correct. I also certify that 1 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 this permit for ju cause Furthermore, I hereb agree that the city official or a designee may enter upon the property to perform needed Inspections.
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 $
T ': A, .1i. • I Becomes Your Building Permit When Approved Paid Receipt No.
Date By
f 2-
`':uildi ( Official ate
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
F a ,, ri + r y t
INTERAGENCY REQUEST FOR BUILDING INSPECTION
4r : 1
{ CHILD CARE CENTERS
To L � nSr .CiDr— Date: 3 ° 9 -
From: ` C "-1,-1 1 COt.iS , (Licensor) Phone Number: ((f51 - Le 1 - b-
Prior to issuing a license to provide child care, verification is required that a facility is in compliance with
appropriate state, county, and local building codes (Minnesota Rules, part 9503.0155, subpart 1). Please
complete this form and return it to the Department of Human Services, Division of Licensing with any orders
attached. A copy of the orders should also be provided to the program.
RI - ia- �D` I �
�Y1nC.A in
Name of Program: License Number: I 0 & 19
P'Lv1 - Lake_ Fait/ CLtdJ"ood. ! {e -
Name of Facility: r /�" l / n
Address: 35 NO en') 1: -revs Rd Mw rA O - 55379
Street City Zip Code
Program Contact Person: 5 Il1.dL.LQ.— TkOn'lCtS Phone Number: 6, /2- -(- 40s - 02-5
Areas to be used: CI ssrooms to be used: Number /Aqe Ranges of Children:
❑ Basement Entire Facility 6 weeks to 16 months: /,
First Floor ❑ Specific rooms listed below: 16 mos. To 33 months: > e,s'
❑ Second Floor 33 mos. To kindergarten: N 3U toils
❑ Other Kindergarten to 12 years:
Specify: Total: X07
Building Inspection Results:
❑ Not Applicable: facility located in non -coded area.
Date of referendum vote removing code requirements:
Signature and Title of Local Official:
54 Facility meets building code requirements.
❑ Facility does not meet requirements and cannot be occupied until orders are met.
❑ Facility does not meet requirements, but may temporarily be occupied until: (date),
pending completion of orders.
Signature of Buil 'ng inspector: j , Phone Number: 4 ' <N7' ` i Z 95� ' (. ) -----
Agency Name: /' 4 ?ter• Log Date: 20// 2
6
When inspection is complete, mail or fax this form and any additional orders to:
Minnesota Department of Human Services, Division of Licensing
P.O. Box 64242
St.Paul, MN 55164 -0242
Fax Number: 651 -431 -7673 T "s.
r ,
Revised 02/21/12