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o � PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
U �
'dj I Whi�e File
2 �;�� � PERMIT NO. � 2_ 5�3 Z-
3 Yelbw Applicant
Please or rint and si at bottom)
ADDRESS ZOIVING (oFlFice use)
5�31� �4���.���-. ��,.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
,
OWNER �
(Name) r���''� tl' � �...;;,i L� (Phone) ��5 ,�-����� '�� ��
(Address)
BUII.,DER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
DAddition �Alteration ❑Udlity Connection
CODE: [� R.C. ❑I.B.C. ❑ Misc. G�4�Jr t ��ISd�1 P`�l�+�' `�� �
Type of Const�uction: I II III IV V A B pROJECT COST/VALLJE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certi'ty that I have fi�mished information on this application which is to the best of my knowledge true and correct. I also certify [hat 1 am [he uwncr or authoazcQ agcnt for the
above-mennoned property and that all truction will conform to all existing state and local laws and will proceed in accurdance with submitted plans. I am aware that the buildmg
official ca ke this p'mit r st i" Furthermore, I hereby agree that the ciry official or a designee may enter upon the property to perform needed mspecuuns.
X ��; � /� :' /�.
Signature ContraMOr's License No. Date
Permit Valuation � Park Support Fee # $
Permit Fee $ � � � SAC # $
Plan Check Fee $ l� 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 $�, �
Thi plic ti ecomes Your Building Permit Wh Ap oved Paid � Recei t NO.
'' Date b - t... B
-L 2
Bi " tlicial ace
This rs to certify that the request in the abuve applicanon and accompanying docu ents is in accordance with the Ciry Zoning Ordinance and may proceeA as requcsted. Th1s document
when si d by t C ry lann consnrotes a trmpurary Certificate of Zoning co pliance nd alluws construction to commence. Before occupancy, a Ccititicate of Occupancy must be
issucd
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Pl te Special Conditions, if any
24 hour noficc for ali inspections (9S2) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372