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oF pR�O� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE � Z� ��
.. x AND UTILITY CONNECTION PERMIT '
U �j
4��'NESO�� �. Wh;�e File pERMIT NO.
2. Pink City ��. ` � /_
3 Yellow Applicant L`� �1�;
Please or rint and si at bottom)
ADDRESS P�„ ��,� �,,,� ZONING (ofTice use)
( 5�5� l 1 5�� � C`� l� S E- ss 3
LEGAL DESCRIPTION (off'ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) �� D ��� �"ln_.�G 2 � (Phone) G1 � 2 �� � "' �. g y �
(Address)
BUII.,DER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
�TYPE OF W�RK ❑ New Construction ❑Deck ❑Porch e-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 YV V A B pROJE.CT COST/VALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 S
1 hcrrby certify that 1 have iumished inPormation un this application which is to the best of my knowledge true and correct. I also certify that 1 am the uwncr or authonud agent for thc
abuve-mennoned prope�ty and that all cunstruction will conform ro all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
official can revoke t's mit f t cyuse Furthermore, I hereby agree that the c�ty official or a designee may enter uQon the property to perform needed mspec ions.
X ' S Z Z
Sign re Contractor's License No. Dare
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 DLJE $� S
This Application Becomes Your Building Permit When Approved Paid Re 1 t NO.
Date �. Z r 2 B
Buildins Utlicia� Date
Th�s �s to certify that the request in the abuve applicat�on and accumpanying documents is in accordance with the Ciry Zoning Ordinance and may proceed as requcsted. Th�s document
when signed by the Ciry Planner consututcs a remporary Certificate of Zoning compliance and allows consrruction to commence. Befure occupancy, a Certiticare uf Occupancy must be
issucd
Planning Direcror Date Special Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372
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