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�,, �, CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
�� TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
" AND UTILITY CONNECTION PERMIT ✓� ' ' ` ',
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�. Wh��e File pERMIT NO. /�
2. Pink City I� � � % I
3. Yellow Applicant
lease e or rint and si at bottom
ADDRESS L,;:' i�� Ju' �',- � ZONING (o�Fice use)
110350 � . � �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDTTION PID
(Na� f���e'n ar SVsO.`(1 V�1eS�r�`C�O�rYI (Phone) ° �� 2 ` � Z�Q — ��12`I
(Address) � �p � `C-�r0 C \ ` L.
BUILDER �` `, {^(� j �
(Company Name) t"C � Q�(1'MO.0 C� � �(„� 'C � �`C S (Phone) � 72 l9� � ' �p ��llt
(Contact Name) �C � S �� `Q,,,�(�Q t" (Phone) � l�' � �� � y �"1 l� �!t
(Address)�'ZZ3� ��0���2� �J �� 1 �
TYPE OF WORK ❑ New Consuuction ❑Deck �Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc:
Type of Construc0ion: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE ��.� OO
Division: 1 2 3 4 5 (excluding land) .
I hereby c at I ha e furnished formation on this application which is to the best of my knowledge true and coneM. T also certify that I am the owner or authorized agent for the
above-menti n prope�y and that construction will conform to all existing state and local laws and will proceed in accordance with submitted plaus. I azn awaze tbat the building
official can e this permit for just e.' Fwthermore, I hereby agree that �he city official or a dEsignee may enter upon the property to peifonn needed inspections.
X � D3 y-1�1
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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This Application Becomes Your Building Permit When Approved Paid R 1 t NO. Z
Date � / � B
Buildin Official Date
This is to certify thaz the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning crompliance and allows mnstruction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Special Condidons, if any
24 hour notice for all inspecUons (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mfinnesota 55372