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o � rRt CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
y ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �� / � ` �j
AND UTILITY CONNECTION PERMIT
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Z �;�, � PERMIT NO.
3 Yellow Applicant / �
Please or rint and si at bottom
ADDRESS ZONING (oft'ice use)
�'�:�[?$' 1S31G' Jc'{{rr� r•�,�
.i'rn/ �a�cl �'s3)Z
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
BUII.DER
(Company Name) —� C'^� �f �"'t � (Phone) 76 3 2 0 2- 6 3�f6
(Contact Name) si• � �.� ���• (Phone)
(Address) n.� ) r'r c C' a^ �,� t a i N sS 6 2
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Conne ion
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Constiuction: I II III N V A B pROJECT COST/VALUE S
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
1 hereby certify that [ have fumished information on this application which is ro the brst of my knowlcdge true and correct. I also certify that 1 am the owner or authonzed agent for the
above-mentioned prope�ty and that all constniction will conform to all existing state and local taws and will proceed in accordance with submitted plans. I am aware that the buiidmg
official can revok is permit for just cause Funhermore, I hereby agree that the city official or a designee may enter upon the property to prrform necded inspecnons.
x �- �03 23��� �p�/y-l/
Signature Contractor's License No. Date
Permit Va ation 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 DUE $
This Application Becomes Your Building Permit When Approved Paid eCel t NO.
Date
Buildin � Uflicial Date
This �s to certify that thc requcst in thr abwe applicanon and accumpanying documents is in accordance with the Ciry Zoning Ordinance and may proceed as requcsted. This ducument
when signed by the Ciry Planner consumtes a temporary Ce�tificate of Zoning compliance and allows construction tu commence. Befure uccupancy, a Ceruficate nf Occupancy must be
issucd.
Planning Director Date Special Coaditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372