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D
oF PR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, `� <. � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
�' " �' � AND UTILITY CONNECTION PERMIT
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M��'NESD�P I. White File �� ��
2 �;�� � PERMIT NO.
3 Yellow Applicant �
(Please e or rint and si at bottom)
ADDRESS ZONING (oeeice use)
y q P� 5 c o�r,oc�e, fa, � 5�
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OwNE ` � n � / / �_ � /
(Name)�,V�. ��'� l (Phone) O' �
(Address) �J �1C,>
BUII,DER ,J,, - I �
(Company Name) �k1-CV`Y�� ��A �r�(.��1� (Phone) L4�� � ��'����
(Contact Name) (Phone)
(Address) I� p� O �. �� C�� W'�O�,UI' � YY11V �S � �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑ ower Leve_ I Fi�y1� Q_Fi�epl�ce�
❑Addition ❑Alteration ❑UtilityConnection �plp`('� ' (,�� ���J� ��2< <✓����
. . �,r : npD .
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc. �Q Q �
Type of Construction: I II III N V A B pROJECT COST/VALUE $ � "�
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certif'y that I have fiunished infqrmation on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorlud agent for [he
above-mennoned prop and that all con tion will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can revoke this rmit for just caus . F i7hermore, I hereby agree that the city official or a designee may enter upon the property to perform needed mspections.
X G� �(' I 30�8 3 ��%7�1Z�-
Signature Contractor's License Na te
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 Pernut When Approved Paid Re i t No.
Date B �
Buildim� Ofticial D�te
This is to certify that the request in the above application and accumpanying documents is in accordance with the Ciry Zoning Ordinance and may proceed as reqocsted. This document
when signed by the Ciry Planner constitutcs a temporary Certificate of Zoning compliance and allows consh'uction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372