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,��i'-``��' �ITY ��+ PI���R LAK� B�JILI)Il'd� PERl����', Date Rec'd
�! j � TEMPORAR�' ���'�'FFI�ATL O�' ZO1�T�l�TG COMPLIANCE
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1. Wliite File ����� �70 �� �
2. Pink City lY
3. Yellow Applicant
(Please e or rint and si at bottom)
ADDRESS ZONING �ot��� L�-�>
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�SYS � /QII�iZL:�9,� /�l�/ JS.���a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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(Nam ) �/G/t F�.E 1J���� (Phone��'' - 3��a
(Address) ���$ ,��Q ld� � /'"J� ��}�'�0
(Company l �G'��✓ (Phone����93 J '� � c� �
(Contact Name) /�����E��-� � (Phone)
(Address) ��3 p � ,�-�c�c � c j /�� ('/1S` s4 l �/I�
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TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteradon ❑Utility Connection
CODE: �I.R.C. ❑I.B.C. ❑Misc: / � � ��' `ld�
Type of Construction: I II III IV V A B � S T? 'v t�}/� C° �/�'� ..�
Occupancy Group: A B E F H I M R S U PROJECT COST/ ALiTE $ 1 �r p �� `
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have fumislied information on this application which is to the best of my knowledge true and corred. I also certify that I am the owner or authorized agent for the
above-mentioned prope an that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am awaze that the building
official can e this ermit ox just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
ti �G�3 �� � 8" /�.3 --lo`�-
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 $ SewerJ W ater 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 $ ��'
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This Application Becomes Your Building Permit R'hen Approved Pdld q � Reeei t o.
Date ,! Z. B
Buildin Official 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 City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
Planning Director Date Specia} Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372