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oF pRt CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
M ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ���/ ��
� AND UTILITY CONNECTION PERMIT
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4�A'NE80�� L White Fi1e �
2 Pink �„ PERMIT NO. Z,
3 Yellow Appiicam
Please or 'm and si at bottom)
ADDRESS �(��z ZONING (o�i use)
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' t�, � �r�.l � 5 �
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER � � � ` ` �
(Name) �...e.J ► C. n t (Phone) � `Z ' 3 � � � a32 �
(Address)
BUII.DER
(Company Name) : �.� � :�' � � ��/�.� (Phone) 7��' 1 'f L� '" 5 � fiL
(Contact Name) �M.L,.,�C� __-- - __--_-- - {Phone) �12- `�7(? 2 � �'7�Y
(Address) (� S S c�ot•�• v r�C. G,' _ I� �� �v.•�•e� S�S 3(o
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �e-RooRng ❑Re-Siding ❑Lower Level Finish ❑ Firepiace
�Addition �Alterarion ❑Ucitity Connection
CODE: ❑I.R.C. ❑I.B.C. O Misc.
Type of Constxuction: I II III N V A B pROJECT COST/VALiJE S � �� o
Occupancy Gronp: A B E F H I M R S U (exclnding land)
Division: 1 2 3 4 5
! hcreby ceRify tha[ I have fumished �nformation on this application which is to ihe best of my knowicdge rrue and correct. I also certify that I am the owncr or authnrizcd agent for thc
above-mennoned property and that ail c nstruction wiU conform to ali exating state and locai laws and will proceed in accordance with submitted plans. I am aware that the buildmg
ufficial can revoke this permit for st e Fuithermore, I hereby agree that the city official or a designee may enter upon the prope�ty to perform necded inspections.
X f3 C�J D�7? 2�s l Z.
5ignature Contractor's License No. ate
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 518"; I"; $
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 Appiicadon Bernmes Your Building Pemtit When Approved Paid R ei t NO.
Date �
Buildi�tie Utiicial Date
This is to certify that the requcst in the above applicauon and accumpanying documents is in accordance with the Ciry Zoning Ordinance and may proceed ie requcs[ed. This document
when signrd by the Ciry Planner conshtuces a tempurary Certificate of Zon[ng compliance and alluws consmiction to commence. Before �xcupancy, a Cernticace ��f Occupancy must he
issucd.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (9SZ) 447-9850, fax (952) 4�t7-4245
4646 Dakota Street Prior Lake, MN 55372