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oF PRlp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ����
� � AND UTILITY CONNECTION PERMIT
U �
'I�j �. Wh,�e File pERMIT NO. '�
2. Pink City / �, • � �
. 3 Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ZONING co��� �Se>
f' �C� � �� �
,
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER /� .� � � � � �
(Name) ����1 �t! � (Phone)
(Address)
BUILDER � _
(Company Name) ° (Phone) �.� " /7 �._�,���
(Contact Name) � � (Phone)
(Address) � �- � � /t/
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Conne tion
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B pROJECT COST/VALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
1 hereby certify that 1 have ti�mished infor tion on this application which is to the best of my knuwledge tnie and correct. I also certify that 1 am the owncr or authonzed agcnt for thc
above-menhoned property nd that a o truction will conform to all existing state and local laws and wilt proceed in accordance with submittcd plans. I am aware that the buildmg
official can rev t' mit f c se Furthermore, I hereby agree that the city official or des' gnee may enter apon the pro ercy to perform necded mspc lons.
X -� � s��'�t�s�
Signamre Contractor's License No. ate
Permi 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 $
This Application Becomes Your Building Perntit When Approved Paid R ei t NO.
Date . Z.
Buildine Utlicial Date
Th�s rs to certify that thc requcst in thr abuve applicauon and accumpanying documents is in accordance with the Ciry Zoning Ordinantt and may proceeA as requcsted. Thrs dixumcnt
when signed by the Ciry Planner consututcs a temporary Certificate uf Zoning compliance and ailows consnuction to commence. Before occupancy, a Ccruficatc of Occupancy must be
issucd.
Planning Director Date Speciai Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372