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o � rR� CITY OF PRIOR LAKE BUILDING PERMIT, • Date Rec'd
� � � c TEMPORARY CERTIFICATE OF ZONING COMPLIANCE � �,� � � �
� �°�;�' � ���` � AND UTILITY CONNECTION PERMIT
U �. t�
��A'NESO�P 1. White File
2. Pink �;, PERMIT NO. �� ��
3 Yellow Applicant
(Please e or rint and si at bottom)
ADDRESS ZOIVING (oft use)
! �7 � 3� �, �, ��'�v G� S
LEGAL DESCRIPTION (office use only) `�'
LOT BLOCK ADDITION 1'ID
OWNER `�
(Name) �� Gi Yl o O � � h (Phone) � 5 � � � T / — y � 3 �
(Address) '� �-,� � T� ev n � � U`� S� 'Y v i�' , K- 2 tnYl 5 J�.3 7 Z
BUII.,DER ,.-�
(Company Name) e1C� � c5o�itxa o.rc�d 1Le,�c�.L (Pnone� Q - G i5 - 7?a,6
(Contact Name) �e.o-rr�� l �i.\ie�tt (Phone) �_�I ,�- —SS',"�- 3 -- � � �
(Address) '-N � d� c.�.\5i C��C' 1 V ��� �S o.vµ V(.�.1 �J�� �C,o
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing Re-Siding . ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection �j (� � . ,
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
1 hereby certify that I have fltmished information on this application which is ro the best of my knowtedge true and correct. I also certify that 1 am the owner or authonzcd agent for the
above-mennoned properry and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted ptans. I am aware that the building
official can r voke this permit for }ust cause. �rthermore, I hereby agree chat the ciry official or a designee may enter upon the property to perform needed mspections.
x ��'�-c.,..[ ��<< �12DU/ U S C> _�v �?�'—l�
� Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/S"; 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 Pemut When Approved Paid R ei t NO.
Date �,, 11-- B
Buildinn Ufticial D�te
This is to certify that the request in the above application and accompanying documents u in accordance with the Ciry Zoning Ordinance and may proceed as requcsted. This document
when signed by the City Pianner consututes a temporary Certificate of Zoning compliance and aliows construction to commence. Befure occupancy a Certificate of Occupancy must be
issued.
Planning Director Date Special Condifions, if any
� 24 hour notice for all inspections (952) 447-9850, faz (9S2) 447-4245 -
4646 Dakota 5treet Prior Lake, MN 55372