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oF PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT ��•��
�
��A'NES��� I. White File `,
Z �;�� � PERMIT NO. y 1 �
3 Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ZONING (o� use�
. O C�-( � --
LEGAL DESCRIPTION (ofi�ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ��.� '�' ,��r'l � ��T (Phone)
(Address) �, �.d � � l S ""
BUII,DER �+ .�,,�,/� �^
(Company Name)S�� ��V`t�'�- r �7{�:1�('� .� C- (Phone) b � � � O � 3 �S � �
� •
(Contact Name) �,���� (Phone) � 3 �t'
(Address) � �t{ � d � �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-RooFing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Acldition �Alteration ❑Utility Connec
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III N V A B PROJECT COST/VALITE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that I have fiimished information on this application which is to the best of my knowledge true and correct. 1 also certify that I am the owner ur authonud agent for the
above-ment�oned property and that all construction will conform ro all existing state and local laws and will proceed in accurdance with submincd plans. I am aware that the buildmg
official can revoke t's per it for ust cause Furthermore, I hereby agree that the city official or a design nter upon the property to perform necded msp •ctions.
X ��3 7 3 12
ignature Co fractor'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 DLJE $ .�—�
This Application Becomes Your Building Permit When ApQroved Paid Rec ' t No.
Date ` B
Buildin � Ut7icial Date
This �s to certify that the request in the above applicat�on and accumpanying documents is in accordance with the Ciry Zoning Ordinance and ay proceeA as requcsted. This document
when signed by the City Planner consntutes a cemporary Certificate of ZoNng compliance and ailows construction ro commence. Before occupancy, a Cert�ticate of Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9RS0, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372