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oF rR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE 5�¢,�Z
.. � AND UTILITY CONNECTION PERMIT
� �
��A'NES��� I. Whi�e File pERMIT NO. �
2. Pink City �.
3 Yellow Applican� /— •
Please or rint and si at bottom
ADDRESS ZONING (ot�'ice use)
�► 3u � � �
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) rY_u�" �cs �.loV✓eS� (Phone)
(Address)
BUII.,DER n
(Company Name) ��U Wa � `� K�� �.�-i � (Phone) � l Z—Zl0 �-�Z��
(Contact Name) �'I�LZ ��.�.�, {-1.► I.� � �`t ° ��+ .-�i s�u � � (Phone)
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteraqon ❑Udlity Conne ion
CODE: ❑I.R.C. ❑T.B.C. � Misc.
Type of Consdruction: I II III N V A B pROJECT COST/VALUE S
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 fumished information un this application which is ro the best uf my knowledge true and correct. 1 also cenify that 1 am the uwner or authonzed agent for the
above-mennoned property and that all construction wiU conform ro ali existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buiidmg
official evoke t is permit for just cause. Furthermore, 1 hereby agree that the ciry official or a designee may enter upon the properry ro prrform needed mspectwns.
X g � t�t. �,r3 .S" � ' ,
Signature Contractor's License No. ate
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 $
This Application Becomes Your Building Permit When Approved Paid � R t NO.
Date . / 2 B '
Buildim_ Utlicial Date
This �s to certify that thc requcst in the abuve applicauon and accumpanying documents is in accordance with the Ciry Zoning Ordinantt and may proceed as requcsted. Th�s document
when signed by the Ciry Planner consumtes a temporary CeiYificate of Zon�ng compliance and allows construction to commence. Before uccupancy, a Certificam of Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 44?-9RS0, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372