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�(J ��, x TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
"`��( ' � `� AND UTILITY CONNECTION PERMIT
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1 . Pin �;i PERMIT NO. j Z�. �� �
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3. Yellotv Applicant
(Please e or rint and si at bottom)
ADDRESS ZONING (ot�ice use)
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LEGAL DESCRiPTION (office use only)
LOT BLOCK ADDITION PID
�aWNER / 1 b{.�-�"� en� � �� (Phone) l6S � �" I S � � �� �
(Address) } � �� � �� S'� �` o � h� � � Pr• c� �ct1 � � �S 3
BUII.,DER � �sa - �y� - � /�/�
(Company Name) (Phone
(Contact Name) �'�i't � ,.. (Phone) � la — �q'O ^s3��
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(Address) � �-� �� j�,., p' �� 1'�f1� .�3`'�
TYPE OF WORK ❑ New Consiruction ❑Deck ❑Porch �e-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 N V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ 1��� -��
Division: 1 2 3 4 5 (excluding land)
I hereby certify thax I have furnished information on this application which is to the best of my knowledge true and correct. I aLso certify that I am the owner or authorized agent for the
above-mentioned pmperty and that all construction 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 permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
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Signature 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 $ ,,�
Tlus Application Becomes Your Building Permit When Approved Paid ReCel O
Date / B
Buildin Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may pmceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Special CondiNons, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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