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oF prt� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �� �I �j
.. AND UTILITY CONNECTION PERMIT `� �
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M�'�'NES��P �. Wh��e File pERMIT NO. 1 /�
2. Pink City /�� d `y
3 Yellow Applicant v L ��
Please e or rint and si at bottom)
ADDRESS ZOI�TING (office use)
I� � �'7 � p s t
LEGAL DESCRIPTION (ofFice use only)
LOT BLOCK ADDITION PID
�
O a WNER � � , ��� _ " ' � (Phone) ��o� — � �'
� '"�S
(Address) � � G ! � �--� 3 �
(Comp ny (Phone) � �3 .� �� 7 `" 7 7 `�
(Contact Name) Os'J �Q� � A K � (Phone) < < � � � �
(Address) ��� �� �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B � �� 6��
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ ��
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have fi�rnished information un this application which is ro the best of my knowledge true and correct. I also certify that I am the ownrr or authonzed agent for the
abuve- property and that con �uction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
offic' can revo e s perm orju ai e. u �more, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X Q C' �d� `1'U4 /7 ��(���%
Signature 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 $ ther s�, �� $ �"'��
Gas Fireplace Permit Fee $ TOTAL DLTE $ Cf'�
This Applicarion Becomes Your Building Pernut When Approved Paid Recei t NO.
Date O B
.�- �_--� // �
Buildim� Ofticial Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the Ciry Planner consututes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Cci7ificate ��f Occupancy must be
issued.
Planning D'uector Date Special Condidons, if any
24 hour notice for all inspections (9i2) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372