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oF rR� CITY OF PRIOR LAKE BUILDING PERMIT, �� � Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �',' <<; ��"'
� � AND UTILITY CONNECTION PERMIT � ° � �'� ���� �M
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+1►jNNes�qD I White File
z �;�� �;, PERMIT NO. ( Z_(� Z�
3 Yellow Applicam
Please e or rint and si at bottom)
ADDRESS � ZONING (ot�'ice use)
� � 3� �,�15��� � �; �, �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�aWNER�,,�-`/C� � S/T �� � � ���.�'L �'"' ( ) � / � ����L.� �
Phone � � /
i�
(Address)
BUII.,DER ` � �^ G''G. TL'��y C � ���p -�a `� � �Y�G�`J �7
(Company Name��-� (Phone,
(Contact Name) '� '°" �" ' � (Phone) �Se�o`� ��� �
(Address) � �G� � �`t /"
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Cons�tcuction: 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 certi'ty that I have fumished information un this application which is to the best of my knuwlcdge true and correct. I also certify that 1 am the owncr or authonzcd agcnt for thc
abuvame oned property and that all construction wil] conform to all existing stare and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
ufficial revoke tK perm or just cause. Fui7hermore, 1 hereby agree that the c�ty officia! or a designee may enter upon the properTy ro perform necded mspcctions.
X ,. � �� � ,� 3 ���
ignamre Contractor's License No. Date
ermit 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 DiJE $
This p icatio ecom Your Building Permit When Approved Paid Recei O. �t �,Z
l �-- Date � B
G r � i-�
uilJina ici.d ate
Th�s �s to certify that [he request in the abuve applicahon and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requcsted. Th1s document
when signed by the City Planner consntutes a tempurary Certificate uF Zoning compliance and allows construction to commence. Befure uccupancy, a Certrticate of Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9R50, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372