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� � CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
" `� AND UTILITY CONNECTION PERMIT
�
f �'N E S��
i P'k �;ry PERMIT NO. �'� ��
3. Yellow Applicant
(Please e or rint and si n at bottom
ADDRESS ,7 ) q 9 L �� /�� �'���c C N• t..� . ZONING �oflf'ice use>
LEGAL DESCRIPTION (office use only) ,
LOT BLOCK ADDITION p�
OWNER
(Name) �O � n -� �, � � Qa 1�v .i (Phone) �S Z. - 8" 3 6 7 / 3�
(Address) .���� Lc��CP ��u� �l r �°(.c-)•
BUII.,DER �/�
(Company Name) E°� �P J'�d'' ^ �� �� qSZ - 7�f 6- 3o s� 6
(Phone)
(Contact Name) i c. wc�- (Phone) �� Z� S� ��� C� g 7 /
(Address) I 3o I E• C�`-� 2�// 7�c.t /�► S� �� l(F ,/K � SS3 3
TYPE OF W�RK ❑ New Construction �Deck ❑Porch [�12e-Roofing ❑Re-Siding �Lower Level Finish ❑ Fireplace
�Addition ❑Alteration ❑Utility Connection
CODE: DI.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE ��s g��
Division: 1 2 3 4 5 (excluding land)
I hereby cer[ify that I have furnished informaflon on this application which is to the best of my lmowledge true and correct. I also cerfify thai I am the owner or authorized agent for the
above-mendoned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am awaze that the building
official can revoke ' pe just ause. �urthermor ffiereby agree that the city official or a designee may enter upon the property to perform needed inspections.
x /gC. ��� 867 Ia�ZO�Z
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 $
This Application Becomes Your Building Permit When Approved Pdid ReCEl t I�TO.
Date B
Buildin Official Date
This is to certify that the request in the above applica6on and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when si�ed by the City Planner consdtutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director � � Date Special Condi6ons, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372