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oF rtt� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
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AND UTILITY CONNECTION PERMIT
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'arjNNE$D�D I. White File pERMIT NO. � �=
2. Pink City I / _ ` �
3 Yellow Applicant � ��
Please e or rint and si at bottom)
ZO1�TI1vG (office use)
ADDRESS ��`� b� � h..l�, I (l�V� �,\��C, ��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1 -�- �yl l'1� � � (Phone) �� Z � � �1' � ��-�
(Name) 1! L��,,a �
(Address) ���, �S (A- b O � �
BUII,DER )� ���� ^ � �
(Company Name) � 1 � � 0. � eGu'v� i V1 5 �- �' ��` �"g (Phone) � 2 � o -
p �.
(Contact Name) �vi c 1 �� one)
(Address) i C3 ✓� s �� �1/�' S Pa r�- Wl l�f 5 S �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connecnon
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B pROJECT COST/VALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that I have fi�mished information on this application which is to the best uf my knowledge tnie and correct. 1 alsu certify that I am the owner or authonzed agcnt for thc
above-men ned propc�ty that a c�nstruction will conform ro all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
ufficial c r oke this per i or jus use. Fu ermore, I hereby agree that the city official or a designee may enter upon the property to perform necde mspections.
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G12.�?,� ��z... IG 1 L
Signature Contractor's License No. ate
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 Whrn Approved Paid �' ei t NO.
Date , (Q_ ''Z •
Buildine Ufticial Date
Th�s �s to certify that the requcst in the above applicanon and accumpanying documents is in accordance with the City Zoning Ordinance and may proceeA as rcquested. Th�s document
when signed by the City Planner consamtes a tempurary Certificate uf Zoning compliance and allows construction cu commence. Befure occupancy, a Ccnificuc uf Occupancy must be
issucd
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fxx (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372