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oF PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE /
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AND UTILITY CONNECTION PERMIT !� • �� ! �
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Mj I. Whi�e File
z �;�, � PERMIT NO. .��
3 Yellow Applicant
Please or rint and si at bottom)
ADDRESS ZOI�TING (of�icc use)
I�J> 1 � J��� Irs > >.S �~�"'L �Kt-- ��
LEGAL DESCRIPTION (oflEice use only)
LOT BLOCK ADDITION PID
OW1vER
(Name) (Phone)
(Address)
BUII.,DER /� �� {.�
(Company Name) `r'�"j, I�''e �'►'l� W� J�. �n C (Phone) 7� 3� 3 j y `'� a 3 y
(Contact Name) �,) ts S � � S Y►�► � � _ (Phone)
(Address) „3 � v '�s�dtS (.-��G�C
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch -Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Uality Conne ion
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B pROJECT COST/VALLTE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that 1 have fi�mished �nformation on this application which is to the best uf my knuwledge tnie and correct. I also certi(y that 1 am the owner or authorized agent for the
abovamenuon property and that all construction will conform ro all existing stare and local laws and will proceed in accordance with submittcd ptans. I am aware that thc buildmg
official can re e this permit for just cause Furthermore, I hereby agree that the ciry official or a designee may enrer upon the property ro perform necded mspcMions.
X �- ao 3��� �o -� �r - i/
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 $
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Y
This Application Becomes Your Building Permit When Approved Paid ✓�' Re ' t No.
Date B
Buildim� Utlicial Date
This �s to certify that the requcst in the abuve applicat�on and accompanying documents is in accordance with the Ciry ZAming Ordinantt and may prixeeA as rcqucsted. This document
when signed by the Ciry Planner consurotes a remporary Cettificate of Zoning compliance and alluws construction to commence. Befure occupancy, a Ceruficam of Occupancy must bc
issued.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372