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oF PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Dat Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE � //
AND UTILITY CONNECTION PERMIT �
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4�NNeso�� I. White File
2. Pink �,� PERMIT NO. ( �
3 Yellow Applicam �
Please or rint and si at bottom
ADDRESS �/ 7� L Q x� � s� ZONING (of�'ice use)
. �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER p '/ p
(Name) /� e�" (Phone) !SZ — �Y 7 r �C a�
(Address)
BiJII,DER
(Company Name) (Phone)
(Contact Name) (Phone)
�Address)
TYPE OF WORK ❑ 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/VALLTE $
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 fumished �nformation on this application which is to the best of my knowtcdge tnie and correct. I also ceRify that I am the owncr ur authonzed agcnt for the
above-mennoned properry and that all construction will conform to all existing stare and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
ufficial can rev ke this prrmit for use. Furt ermore, I hereb agree that the c�ty official ur a designee may enrer upon the property to perform needed ms ectio .
X
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 $ ,
This Application Becomes Your Building Pemvt When Approved Paid R i t NO.
Date
Buildin � Ufticial Date
Thu is to certify that the requcst in the abuve applicanon and accumpanying doc�ments is in ac�ordance with the City ZAming Ordinance and may proceeA as requcsted. Thrs document
when signed by the City Planner consututes a temporary Certificare of Zoning compliance and allows construction to commence. Befure ixcupancy, a CcrnficaM uf Occupanty must be
issucd
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372