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o � pR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
U �
��N o��' � Wh�,e File pERMIT NO.
NES 2. Pink City ��.. /` ��
3 Yellow Applicant
Please or rint and si at bottom)
ADDRESS ZONING ca���� �5�>
I a3 I���d,e,�r��esS�r�;l ��
LEGAL DESCRIPTION (office use onty)
LOT BLOCK ADDITION PID
ow�R Ca � � r1 �o�.. ��.r � ► 5 � 9� a � y�l6 - � � �
(Name) Phone)
(Address) �'
BUII..DER c > � - a � y " l.� �.�..�.
(Company Name)�'����`h��� �� �� (Phone) �
(Contact Name) (Phone)
(Address) \� Q� �. �• ��G' � W �S�" ' � � 11e � � �
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplac �
❑Addition ❑Alteration ❑UtilityConnection � nla� �j (�V��ws C���r1 ��! 5
„vt' � Q� � � '
❑ Misc.
CODE: ❑I.R.C. �I.B.C.,_ �
Type of Construction: I' II III N V A B pROJECT COST/VALUE $ ��) �
Occupancy Group: A B E F H I M R S U (excluding land)
Division: ` 1 2 3 4 5
L hcreby ceRi'ty that 1 havr fumished mformation on this application which is to the brst of my knuwlcdge true and coirect. I also ttRify that 1 am the uwncr ur authunud agcnt for thc
above- enuoned property and that all cunstruction wiU conform ro all existing sWte and local laws and will proceed in accordance with submittcd plans. 1 am awam that the buildmg
I offici can revoke thi it for �ust caase Futthermore, I hereby agree that the aty official or a designee may enrer upon the property ro perform needed mspecuons.
X �C13b9�3 50C�
Signature , Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Nleter 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 $ . 7
This Application Becomes Your Building Permit When Approved Paid ReCei t N .
Date 0 B
Buildina Ufticial Date
Thu �s to certify that thc requcst in thr abuvr applicauon and accumpanying documents is in accordance with thc Ciry Zoning Ordinancc and may proceeA ax rcqucsted. This documcnt
when signed by the Ciry Planner consnmms a tempurary Certificate uf Zoning compliance and allows construction tu commence. Befurr uccupancy, a Cerhficate nf Occupanty must bc
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) �47-9A50, fax (952) a47-4245
4646 Dakota Street Prior Lake, MN 55372