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oF rR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
U �j
�� NES �� I. White File
N O 2. Pink �,� PERMIT NO. �z _ �; �,c�.7
3 Yellow Applicant
Please or rint and si at bottom)
ADDRESS ZOIVING (ottice use)
. � �l 2`�- Oa � Ca��- .. � � .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I
(Name) 1 1 r� S � hn �� fd�+ (Phone)
(Address) l e 'L iJ Ctl-f �- , £ _
BUII.,DER q
(Company Name) �t (Phone) / �' � � ? �' Y `l � $
(Contact Name) Se (Phone)
(Address) �� �o `I 1�t, � �, �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �2e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utiliry Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III N V A B pROJECT COST/VALUE $ �� Q '`' °
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
[ hereby certity that I have fumished information un this application which is to the best uf my knowledge true and correct. 1 alsu certify that I am the i�wncr or authonzed agent for the
above-mennoned pro •rry and that all construction will conform ro all existing state and local laws and will proceed in accordance with submittcd plans. I am awam that the buildmg
official can rev is rmit for cause. Fu ore, I hereby agree that the city official or a designee may enrer apon the property to prrform necded mspections.
X q� G3Y fa 1 �—�� —( L
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1' ; $
State Sureharge $ 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 DLTE $ ,�
This Application Becomes Yow Building Permit When Approved Paid Recei N
Date B ' �
Buildin � Utiicial Date
This �s to certify that the request in the abuve applicanon and accumpanying documents is in accordance with the City Zoning Ordinance and may proceeA as requcsted. Th�s ducument
when signed by the City Planner constitutes a rempurary Certificate of Zoning compliance and allows construction ro commence. Before uccupancy, a CeruFicuc uf Occupancy must bc
issucd
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