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o � rR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, �. TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� � AND UTILITY CONNECTION PERMIT
U �
��NNESO�� i, White Fik I nERMIT NO . C Z ^,' ���
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3 Yellow Applicant
Piease or rint and si at bottom
� ADDRESS � ZONING to� use)
23� p
LEGAL DESCRIPTION (oflf'ice use only)
LC1T BLOCK ADDITION PID
OWNER� / ' �y �,/
(Name) !/!/! r [ � (Phone) 'V !?— _
(Address) r O G� � �
BUII,DER
(Company Name) �`� � �� (Phone)
(Contact Name) G t- (Phone) � o� d d��l '�
(Address)
� TYPE OF WORK ❑ New Construction ❑Deck ❑Porch e-Roofing e-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: I.R.C. ❑I.B.C. ❑ Misc.
Type of C nstruction: I II III IV V A B pR03ECT COSTNALLTE $
Occupancy Group: A B E F H I M R S U (excfuding land)
Division: 1 2 3 4 5
! hereby certify that [ have fum ed information un this application which is ro the best of my knowledge true and correct. t also cectify that 1 am the owncr or authonzcd agent for thc
above-menhoned property a at ail cunsiruction will conform to all existing state and local laws and will proceed in accordance with submitted plans. 1 am aware that the buildmg
ufficial can r ke this r just cause Furthermare, I hereby agree that the city official ar a designee may enter u n h pro erty to perform necded inspections.
� x �--- � � � 3 1 � � � �C1 �zZ / Z
Signature Contractor's License No. Date
Permit Valuation S� i Park Suppor[ Fee # $
Permit Fee $ Q SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ Z,,, Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Fermit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DiTE $ � s
This i'on Bernaus Your Building Pemnit rn Ap ved Paid Recei t NO.
.----------�- Date o B
Z?i Z-
Buildina Ufticial Date
This is to certi(y that the request in the above application and accumpanying documents is in accordance with the City Z.oning Ordinance and may proceed :�c requcsted. Thls document
when signed by the Ciry Planner constitutes a tempurary Certificate of Zoning compliance and allows consU'uctinn to commence. Before �xeupancy, a Cen�ficau uf Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952y 447-985(1, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372
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