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oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE �- j( r�
.. � AND UTILITY C4NNECTION PERMIT
U �
'�'�Hxeso�h �. wn��e File pERMIT NO . , Q'Q'��
2 Pink City
+ Yellow Applicant � [ � L/ �
Please or rint and si n at bottorn)
ADDRESS ZONING (oft use�
� tu t (� Z-. �.�t � t� �?�C,� � ✓� �r i t7c-- �. �� NL I� SS� �"�--
LEGAL DESCRIPTION (office use oniy)
LOT BLOCK ADDITION PID
OWNER j �_
(Name) � c ��-e. l� � � ��� (Phone) � � Z- " � �� " `�' � �P (
(Address)
BUII,DER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing e-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition DAltexation ❑Urility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: 1 II III IY V A B pROJECT COST/ VALUE S
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hcreby certify that ( have fumished information on this application which is to the best of my knowtedge true and cvtrect. I also certffy that t am the owncr or authorizcd agcnt fur thc
above-mennoned proprrty and that ail consmuction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
ufficial c ke Uii rmit r just cause F� 6ermore, I hereby agree that the city official or a designee may enrer upon the property to perform necded ms}xctinns.
� X < 3 � �
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 $ Wacer Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Percnit Fee � Other $
Gas Fireplace Permit Fee $ TOTAL DUE $ ,!
This Appiication Becomes Your Building Pem�it When Approved Paid . Re t NO.
Date � / Z,� B
Buiidina Utticial D�te
This is to certify that the request in the above appiication and accompanying documents is in accordance with the Ciry Zoning Ordinance and may prixred as requcxtcd. This ducument
when signed by the Ciry Pianner constuutes a temporary Certificate ot' Zoning comptiance and allnws construction tu commence. Befure �xcupancy, a C�vuticate uf Occupancy must bc
issucd.
Planning Director Date Special Conditions, if any
24 hour notice for ali inspections (952) 447-9850, fax (952) 447-�1245
4646 Dakota Street Prior Lake, MN 55372