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of PRI O ,p CITY OF PRIOR LAKE BUILDING PERMIT,
'� c TEMPORARY CERTIFICATE OF ZONING COMPLIANCE Date Recd
AND UTILITY CONNECTION PERMIT S S. "
41 NNE SDlP
I. White File I PERMIT . MIT NO
3 Yellow City O
Please , e or , rint and si n at bottom) 3 Yellow Applicant
ADDRESS
17� � - ZONING (office use)
`� fit nt,f- C ` cie
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER ,
(Name) CJ -' c(' Y tlI Gld -
(Phone) 11; 4790 q0 Z 4
(Address)
BUILDER
(Company Name) (-4/1/ t t / 6K 1. -
(Contact Name) Ter.r7 (Phone) TO Z ��{��g 8
(Address) 91 /2r,...N- (Phone)
TYPE OF WORK ❑ New Construction ❑Deck
❑Porch DRe-Roofing
CODE: ❑I.R.C.
Type of Construction:
Re- Siding DLower Level Finish ❑Fireplace
❑Addition ❑Alteration ❑Utility Connection
❑I.B.C.
❑ Misc.
I II III IV V AB
Occupancy Group: A B E F HI MR S U PROJECT COST /VALUE $
Division: 1 2 3 4 5 (excluding land)
1 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 this permit for just cause. Furthermore, I hereby agree t . he city official or a designee may enter upon the property to perform needed inspections.
X ' �l�t
ignature c h . Cd 1
Contractor's License No. Date
Permit Valuation
Park Support Fee # $
Permit Fee $
SAC # $
Plan Check Fee $
Water Meter Size 5/8 "; I "; $
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 , 06
This Application Becomes Your Building Permit When Approved ?.�
Paid ly I ceipt No. 5 �,_
Date S—.1.----a/ I
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
when signed by the City Planner consulates a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy,
issued. Y proceed as requested. Tans b document
a Certificate of Occupancy must be
Planning Director
D ate Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street Prior Lake, MN 55372