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CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE " AND UTILITY CONNECTION PEW/11T
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1 . White File
2. Pink City PERMIT Na -
3. Yellow Applicant ( i ��
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 %C) c 04 ( .41-:
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1, (( Iy�
(Name) I Il S ' ( Phone 12 ) W() ''9, 7C) -
(Address) Ni 30 . 5 tAlt, I N - «//
BUILDER � n
(Company Name) ''nn WA V∎/1? si` nit s ,1-11- Li / 6C.W`11 Z2 S (Phone) 626i) �2 . -(3 3 G
(Contact Nam h �Me� , � � f (P hone) f - WIZ) 7..2 K &5 sue!
(Address) 1 10..141' CQo t q---ic.J LIIWd Lic_e_r
TYPE OF WORK ❑ New Construct(.gn ❑Deck OPorch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
❑Addition Alteration ❑Utility Connection } t ( ,
CODE: DI.R.C. I.B.C. Sisc: O4i411.1,v. t `t 'tY� 04(4 iI u-"'1�C -- -t lit....-NO �� �T
e01. (
Type of Construction: I II III IV V A B t vice b �
Occupancy Group: A B E F H I M R S U PROJECT COST /VALUE $ �,C1
Division: 1 2 3 4 5 (excluding land)
I hereby certij_rhat I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the
above -men} n property a tha all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official cafe r f i s peon for t rause. Furthermore, I hereby agree that the city official or a designee may enter u property perform the to orrn needed inspections.
, x . 1 x 6 A 9 L P q •D-> ;51)- ) d-
v- 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 $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $
0
This Amino. , ; : co1nts Yornt Building Permit When Arpraved Paid Receipt No.
3 / , Date By
Bu i ' .g Official Date
This is to c : I at 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 Special 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