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o � PR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� C TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT ��' ` � Z—
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4�HN830��' �. wnue �ae { pFRMIT NO . j� , l U�
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; Yellow Applicant
Ptease or rint and si at boitom
ADDR�SS �� ��� �� � � � �� � ZONING (otl�ice use�
/ C.�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
� � 2` �� � � J C�L- 2�'J�'1 j/') r� (Phone)
ti/
(Address) (i I�e1� � �"D N
BUII.DER Q � (�
(Company Name) ,���� I�C�.I �i�,`.a (Phone)
(Contact Name) � � E (Phone)
(Address) a' V 5
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alterarion ❑Utility Conn ction
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III TV V A B PROJECT COSTlVALUE S
Occupancy Group: A B E F H I M R S U
Division: 1 2 3 4 5 (exclnding land)
i hrreby certify at I have fu ' ed information on this application which is to the besi of my knowledge tcue and carect. [ atsu cerufy thaz [ am the vwner or authorized agent for the
above-menno propc�ty at ail cunstruction will conform ro all existing state and (ocal laws and will proceed in accordance with submitted pians. I am aware that the buiidmg
ufficial can ke this or ust cause. Furthermore, I hereby agree that the city official or a designee may enrer upon the propecty to perform necded mspections.
� X ' �7 O�/v�/ y
� Signatur Contraetor's License No. � Date
Permit Valuat'ron Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size SIS"; i"; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Perrnit Fee $ Other $ �
Gas Fireplace Permit Fee $ TOTAL DUE $
This Appiicallon Becomes Your Building Permit Whrn Approved Paid � Cei t NO.
Date ,, � � Z
Buildine Utiicial Date
This ic to certify that thc requcst in the above applicat�an and accumpanyin� documents is in accordance with the Ciry Zoning Ordinance and may proceed as requcsted. This document
when signed by the Ciry Ptanner conchmtes a tempurary Certificate uf Zoning compliance and allows construction to commence. Befure �xcupancy, a C�vuticate af Occupancy must bc
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for �ll inspections (952) 447-9850, fax (952) 4i7-�3245
4646 Dakota Sueet Prior I.ake, MN 55372