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o � rR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �' �� /�
.. � AND UTILITY CONNECTION PERMIT
� �
a� I White File pERMIT NO ' /v�
2 Pink City
3 Yellow Applicant !
Please or rint and si at bottom
ADDRESS ZOIVING (ottice use)
�C� �%� /�,/,���c':� L,A�� ` ,��C�- L�1l�C- M:�J g `� �� 7—
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) � I � a-t��1 � ,.. J . ��.a4 J k'-C- I K, (Phone) c1 �Z ' ��t' • � .5� [�3
(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
❑Addition ❑Alteration ❑Utiliry Connection �
CODE: ❑I.R.C. ❑I.B.C. J� Misc. W ��d � �s ; � ��-��
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 (ezcluding land)
Division: 1 2 3 4 5
1 hereby erti that 1 have fumished infor on n this appl' tio �c to e best uf my knowlcdge true and correct. 1 also certify that I am the owncr or authonzed agent for thc
above- nu ned property and all c truc will fo o al istin tate and tocal laws and will proceed in accordance with submitted plans. I am aware that thc buildmg
ufficial c evoke this per r st se. F erm c, eby th e city official or a des�gnee may enter upon the prope�ty to perform necded mspectiuns.
X ry - .s'/ - /�
Signaturt Contractor's License No. Date
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 When Approved Paid CJ �1f R i t NO.
Date
Buildim� Ufticial Date
Th�s �s ro certify that the requcst in the abuve applicat�on and accompanying documents is in accordance with the Ciry Zoning Ordinantt and may proceed as requcsted. Th1s dixument
when signed by the Ciry Planner consututes a tempurary Certificate of Zoning compliance and allows construction tu commence. Before occupancy, a Ccitdicate uf Occupancy must be
issucd
Planning Director 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
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