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�; ��' !, �\ \`�'� TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
"`�•' ���:'� `� AND UTILITY CONNECTION PERMIT
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�. Wh,�e F��e pERMIT NO. f 2 C�
2. Pink Ci[}'
� 3. Yellow Applicant
lease or ' and si at bottom
ADDRESS ZONING (ot�'ice use)
�" / + 1 � � ) �,,
� J l�� �S! C..^(/� V � Pi� �Y'� U'C. ��'� c�/' �G..f� / , /
LEGAL DESCRIPTION (ofleice use only)
LOT BLOCK ADDITION PID
(ONWNER Pc.l c�-� t .2. �� (Phone) �5 `�� --�� � ,. �S3
caaar�s> J�`1� � 2 s 1� l� � ��
BUII,DER
(Company Name) �� ��� �h �-- (Phone) � S a— yy`� " �{��
(Contact Name) _ ��'`S� �/� _ (Phone) � � a - �Q � S�
(Address) ���� �� S.� ��"�Ov' p`� /' l� ����
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ��$Q-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addidon ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Gronp: A B E F H I M R S U PROJECT COST/VALUE $��/�
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have fumished information on this application which is to the best of my knowledge true and coaect. I aLso certify that I am the owner or authorized agent for the
above-mentioned properry 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
official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the properry to perform needed inspections.
ec-�3���� �-1�-�a
Signature Contractor's License No. Date
Perinit Valuarion 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 $
Tlris Application Beco�es Your Building Permit When Approved Paid 1 t NO.
Date ,eC �<
Buildin Official Date
This is to certify that the request in the above application and accompanying document� is in accordance wiffi the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. $efore occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372