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oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ��. �� j ��
.. � AND UTILITY CONNECTION PERMIT
U �rj
'yj I. Whi�e File pERMIT NO.
2. Pink City / � e ��,
3 Yellow Applicam
Please or rint and si at bottom)
ADDRESS ZONING (oFl�'ice use)
�`�33 � � s �..��..� �-{, r - r � .�� �h � �- � �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
owr�R � C_ 0 2�--c � �� Z- `l `�'7- 51 �2_�'r
(Name) (Phone)
(Address)
BUII.,DER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK ❑ New Construction ODeck ❑Porch ❑Re-Roofing Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utiliry Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Constiuction: I II III IV 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 un this application which is to the best of my knowledge true and corcect. 1 alsu crRify that I am the owner or authonzed agent for thc
above-mennoned property and that construction will conform ro all existing state and local Iaws and will proceed in accordance with submitted plans. I am awam that the buildmg
official can revo is p mit for j ca se F hermore, I hereby agree that the city official or a designee may enter upon the property ro prrform necded mspections.
X �
Signature Contractor's License No. Date
Permit Vatuation 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 cei t I�1o.
Date . / B �
BuilJine Utlicial Date
Th�s is ro certify that thc requcst in the abuve applicauon and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requcstcd. Th�s document
when signed by the Ciry Planner consututes a temporary Cettificare of Zoning compliantt and allows construction tu commence. Before oaupancy, a Ceruficate uf Occupancy 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