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oF PRIp� C'ITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
�, � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
v �,
4�kNES��r i, White File
2. Pink City �PERMIT NO . /� �%�/ �
; Yellow Applicant �G
P(ease or rint and si at bottom
ADDRESS ZONING (ottice use)
- JS 6 s� ` r � � _
LEGAL DESCRIPTION (oflFice use only}
LOT BLOCK ADDITION PID
OWNER �-
(Name) J D � �l � ��^-�-i' �'J'� C l., `�, a - (Phone) 6 / � _ � 3 d . �3 5 3 �
(Address) �p -- L L vc�s ^" ( �"�1'
BUII,DER
(Company Name) 1� �t r � �n � �rvcr'l�bn l � L (Phone) ��7 - '�S �- 6�!�Z
(Contact Name) �C,v = c-F "'t G t �. �6-er- � (Phone)
(Address) 3' $ t n�o�• e s � 1 v N�l C S v� .�-� d
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ofing [�Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteraaon ❑Utility Connection
CODE: ❑I.R.C. �I.B.C. ❑ Misc.
Type of Construction: I II III N V A B
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 fumished information on this application which is ro the best uf my know►edge mue and correet. f also cecti(y thac f am the owner or authonzed agent for the
abuve-mennoned prope�ty and that ait construetion will conform to all existing state and local laws and will proceed in aceordance with submitted p►ans. I am aware that the buildmg
utFicial can oke this permit for just ca se. hermpre, I hereby agree that the city official or a designee may enter upon the property to perform necded mspcctions.
x � /� � �,s •� `7 3s � o��S.�i.?
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/Wacer 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 Bui[ding Pern►it When Approved Paid ReCei t
Date ,�3 /L B �
Buildine Utlicinl Date
This �s to certify that the request in she above applicahon and accumpanymg documents is in accordance with the Ciry ZA>nin� Ordinance and may proceed as requcs[ed. This ducument
when signed by the City Planner a>nsututes a tempurary Certificate of Zoning complianee and alluws constniction to commence. Befure �xcupancy, a C�ruficate of Occupancy must be
issued-
Planning Director Date Special Conditions, if any
24 hour notice for alt inspections (9S2) 447-985p, fax (952) 447-d245
4646 Dakota Sueet Prior Lake, MN 55372