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oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
U �r
��NNESO�� I Whi�e File pERMIT NO. � 9� J
� ?. Pink CitY / � —
i Yellow Applican� �
(Please e or rint and si at bottom)
ADDRESS ZONING �oFf"��� u5e>
kC��� � �.�, S , �
LEGAL DESCRIPTION (of�ice use only)
LOT BLOCK ADDITION PID
owr�x � S /� - /C �'`J`�,� �f1' � � � ��
(Name) (Phone)
(Address) � ��i �l��U�� � �J� �
BiJII,DER � �/> �/� �,�'"�``�
(Company Name) � �b/`� � C Gf '�'�� (Phone) ���^ / /
(Contact Name) ` l� C U�� � (Phone)
) �
(Address) L � c� � � , � . O L ��
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TYPE �F WORK ❑ New Construction ❑Deck ❑Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Con ction
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III N V A B PROJECT COST/VALUE $ 6 � _
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I h�Keby certify that I have fumished mformation on this application which is tu the best of my knowicdge true and correct. 1 also certify [hat 1 am the owner or authorizcd agent for thc
abovc-meniioned properry and tha[ consauction will conform to all existing swte and local laws and will proceed in accordance with submittcd plans. I am aware that thc buildmg
ufficial ca rrvoke this per it for ju c ise. Fmthermore, I hereby agree that the city official or a designee may enter upon the property to prrform necded ms •Mions�
� X ,��DO �2 � �U i
Signamr 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 DiTE � _ 7 j
This Application Becomes Your Building Pernut Whrn Approved Paid _ Recei t O
Date B
Buildina Utlicial Date
This �s to certify that thc requcst in the abovr applicauon and accompanying documents is in accordance with the City Znning Ordinance and may prnceeA as rrqucsted. This dixument
when signed by the City Planner consumtes a tempurary Certificate uf Zoning compliance and allows cnnstruction tu commence. Before uccupancy, a Certificate �>f Occupancy must be
issucd
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 44'1-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372