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oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� X AND UTILITY CONNECTION PERMIT
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'bj�, 1. White File '
,,� z �;�� �;, PERMIT NO. �� �, �j ��/
3 Yellow Applicant _— — —� . _
Please or rint and si at bottom)
ADDRES � � � � •-'. p ZONING (otticc use)
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LEGAL DESCRIPTION (ofiice use only)
LOT BLOCK ADDITION PID
�aWNER_�//��r �'1 � �'�G i"? ��T`.Z (Phone) ` �� � �� � �
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(Address) � � � �j'� `c � /l
BiJII.,DER � / (��� � 1� �/ � ��
(CompanyName) .�l'�� �� .1�� (Phone) < <
(Contact Name) � � (Phone} '� �
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(Address) l 3 � ci� '�" �p F� • hS � ��
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Constiuction: I II III N V A B pROJECT COST/VALiTE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
[ hereby certify that 1 have fumished information un this application which is ro the brst of my knowledge true and correct. I also certify that I am the owncr or authonzed agent for the
abovamennoned property and that all construction will conform to alt existing state and local laws and will proceed in accordance with submicted plans. I am aware that the buiidmg
official can vo this permit for just cause. Futthermore, I hereby agree that the city official �r a designee may enter upon the propecty t� prrform needed ms ctions.
I X . - ��. I a -�%�° �
Signature ontractor s License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/S"; 1"; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $`,,, Water Tower Fee # $
Mect�anical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $ „ 7�
This Application Becomes Your Building Peanit Whtn Approved Pald ReCel t o.
Date B
Buildim� Utlicial Date
This �s to certify that the requcst in the above applicanon and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as reqursted. Thls document
when signed by the City Planner consnmtes a tempurary Certificate of Zon�ng compliance and allows construction ro commence. Befure occupancy, a Cernficam uf Occupancy must be
issucd
Planning Direcror Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372