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o � PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �� —) U, t
AND UTILITY CONNECTION PERMIT � �
U �
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��A'NESO�� �. Wh��e File pERMIT NO. ,_ ��
2. Pink Ciry
3 Yellow Applicam
(Please or rint and si at bottom)
ADDRESS t ZOIVING (otlFice use>
�'Jo��g Woo��tit�� �In�
LEGAL DESCRIPTION (oflE'ice use only)
LOT BLOCK ADDITION PID
OWNER � ���I � /
(Name) �„ AV� 0.�N) YY1 � _ _ (Phone) b � � � oZ g o� ' � � � I
(Address) 3a 1� W O O d�� � r' 1� �""
BUII..DER I_ I Q � G q S� �� g. ���
(Company Name) l� n eS �a � O� �''a (Phone)
(Contact Name) � N (Phone)
(Address) � J �.� � �'�41 ��t 1V ,����
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connecti�
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Constiuction: I II III IV V A B pROJECT COST/VALiTE S �� �� �
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certif'y ave fiimished information un this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authonzed agent for the
abuve-menn ed pro rty and that all construction will conform ro all existing state and local laws and will proceed in accordance with submitted plans. I am awaze that the buildmg
official ca evoke s permit for just cause Furthermore, I hereby agree that the city official or a designee may enter upon the property to prrform necded ins ections
X ao63 � �3a �o �o ��
Signature Contractor's License No. Date
Permit Valuation 6 G , Park Support Fee # $
Permit Fee $ � 7� SAC # $
Pian Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ S �� 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 $ 7�'7
This Application Becomes Your Building Permit When Approved Paid ���'� Recei t NO.
/�'� C��� 1 Date _ - 1 B
�-�a-��
Buildins Ufticial Date
This rs to certify that thc requcst in the above applicat�on and accompanying documents is in accordance with the Ciry Zoning Ordinantt and may protted as requcsted. Th�s ducumcnt
when signed by the City Planner consntutes a tempurary Certificare of Zoning compliance and allows construction to commence. Before uccupancy, a Certificate of Occupancy must be
issucd
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372