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� � CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
D� TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �/
" AND UTILITY CONNECTION PERMIT ��� `1_ l'�..
� ��'
NNES�
�. wh�te File pERMIT NO.
2. Pink City / 7 � S ��
. 3. Yellow Applicant �
lease e or rint and si at bottom
AD]��$$ g6�{ - 3 86 aJ PJ � L ZONING (ott use)
LEGAL DESC1tIPTION (ofl['ice use only)
LOT BLOCK ADDITION pID
OWNER
(Name) � e 7 u � � �r S f /� S 3 Jc.��j 01� (Phone) 9 S2 ' 2 7 g' r 7�
(Address)
BUII.,DER /
(Company Name) � �� E/ f nP�� J �^� . (Phone) ?� � 20 2-63�'6
(ContactName) cJv3t�-� S^��h (Phone) 763- 2oa '6 3 � 6
(Address) � 3 `{� � � 0(4� �'/ �., �ict �(a 6
TYPE OF WORK ❑ New Construclion ❑Deck ❑Porch �Re-Roofing ❑Re-Siding �Lower Level Finish ❑ Fireplace
❑Addition �Alteration ❑Utility Conn on
CODE: ❑I.R.C. �I.B.C. ❑ �s��
Type of Construction: I II III IV V A B 2 S 7y6. �a
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ /
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have fumished information on this application which is to the best of my knowledge true and coaect. I also certify that I am the owner or authorized agent for the
above-mendoned roperty and that all mnstruction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am awaze that the building
official can revok ' permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to peiform needed inspections.
x �: � BC 3 2 3 S�f� S'-so -l2
Signamre Conuactor's License No. Date
Permit Val tion 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 Pernut When Approved Paid Recei O.
Date B
Buildin Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the Ciry Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows conshuction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Special Conditions, if eny
24 6our notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mionesota 55372