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oF rR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �y �� `/
X AND UTILITY CONNECTION PERMIT �
U �
��HHeso'�� i wn��e File pERMIT NO
2. Pink City
� 3 Yellow Applicant
Please or rint and si at bottom
ADDRESS ZONING (ott'ice use>
.� � � � d C A�'� ✓`a �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER / ��/ ,/ � / / I
(Name) ��^ Zr� -� C(�/vC 4 r� 'W 2 � Ll� �( T (Phone)
(Address)
BLTII..DER (
(Company Name) Iti �` I ���'+- �ro �� I�one) �o S - g Y��!
(Contact Name) � a �, (Phone) �
(Address) G} ` �ct r' � : � /j/� �—� d`Z
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alieration ❑Utility Conn ti
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: 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
I hereby certify that 1 have fiimished �nformation on this appiication which is to the best uf my knowlcdge true and correct. I alsu certify that I am the uwner or authonzed agent for the
above-mennoned properry and that all constru tion will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
uff'icial can revo this permit for just cause erthermore h y agr that the c�ry official or a designee may enter upon the property to perform nreded u�spections.
X aod 3 a� �� g - i�
ignature 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 $ . 7S"
This Application Becomes Your Building Permit When Approved Paid ei t NO.
Date
Buildine Ut7icial Date
This �s to certify that thc request in thr above applicanon and accumpanying documents is in accordance with the Ciry Z.�>ning Ordinance and may protteA as requcsted. Th�s dixument
when signed by the City Planner consumres a rempurary Certificate uf Zoning compliance and allows construction to commence. Befure occupancy, a Cenificate uf Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for All inspections (952) 44'7-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372