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o � rRt CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
.�. � AND UTILITY CONNECTION PERMIT
U �j
A►jNNes���` 1. White Fik
2 �,�, �„ PERMIT Na r� ' ��o
3 Vellow Applicam
Please or rint and si at bottom)
ADD I S a a 3� �_ I(� � 1r'► �ej ZOI�TING (office use)
� �eer , e��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
owx�R M��� �► o� o� 95 �-�I � o- 6 I s�8
(Name) (Phone)
(Address) �� oC o� ��Q,.e.Ir Y j N�C.
Company�Name) � �i '�. � Y��71� O� l�t�'D �-�Q (Phone) q S � . 3 �"O • S
,
(Contact Name) (Pho e)
(Address) � � � � K�iN1 O N � ( � � ��-e /� ��� �
TYPE OF W�RK ❑ New Construction ❑Deck ❑Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B PROJECT COST/VALUE $��d
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 information on this application which is to the best uf my knuwledge true and cocrect. I alsu certify that I am the owncr or authunzed agent for thc
abuve-men d property and that all construction wiU conform to ali existing state and local laws and will proceed in accordance with submi[tcd plans. I am aware that thc buildmg
offic' can re ke this permit forjust cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed ms ections.
X ao�3�a3� io iv ��
Signature Contractor's License No. Da e
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 C ReCei t No.
� Date B
�G cG-ll
BuilJins Utlicial Date
This �s to certify that thc requcst in the above applicauon and accompanying documents is in accordance with the City Zoning Ordinance and may prnceed as requcstcd. Th�s document
when signed by the City Planner consnrotcs a temporary Certificate of Zoning compliance and allows construction t� commence. Before occupancy, a Ccrtrticam uf Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fAx (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372