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o �' CITY OF PRIOR �.�.IKE �iJII,DII\G P�Y�1�I'�', Date Rec'd !
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LEGAL DESCRIPTION (oftice use only)
LOT BLOCK ADDITION PID �;
OWNER (/
(Name) � �-1 � �� � 1 � f '` _ (Phone)
(Address) � �`QJ'� (,�„i/ � � 1�'f fl� L�t.ke 553� �
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BUlLDER /� �
(Company Name) �QI� �' ��S O� �VJ L- � �— (Phone) % Sc�-��� � 9g� '
(Contact Name) �a�(? i�V1 I S .�U ✓n S (Phor�e) � S a ^ �� � �� � _ � !
(Address) �(P� 2IGOl�'7L l�eY1 u� 1� Y� 1�2 IS ,ss' ��— I
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TYPE OF WORK ❑ New Construction �Deck []Porch �Re-Roofmg �Re-Siding ❑Lower Level Finish ❑ Fireplace i
❑Addition �Alterarion �Utility Connettion l
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CODE: �I.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Gmup: A B E F H I M R S U PROJECT COST/VALiTE $
Division: 1 2 3 4 5 (excluding land)
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I hereby certify that I have furnished information on this application which is to the best of my ]mowledge true and correct. I also certify that I am the owner or authorized agent for the
abov property 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
o cial can revo this per t forjust 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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� �G�O�-15 � ��l � � �
Signature Contractor's License No. Date
�:
Pexmit Valuation Park Support Fee # $ 'i
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Permit Fee $ SAC # $ t�
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
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State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
i
Sewer & Water Permit Pee $ Other $ }
Gas Fireplace Permit Fee $ TOTAL DUE $
Tlvs Application Becomes Your Building Permit When Approved Paid R C t NO.
Date B _
Building 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 proceed as requested. This document t�
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 Conditions, if any j
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 i
4646 Dakota Street S.E., Prior Lake, Minnesota 55372