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CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE n
AND UTILITY CONNECTION PERMIT `� - l�
NBSp�� I. White File
2 Pink City PERMIT NO. /2, l bas
3 Yellow Applicant „.
_iPlease type or print and sign at bottom) ,
DRESS ZONING (office use)
( ' JACK_ ,( 11/4 ST cAl
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((N c)f\ 0 (Phone)
(Address) ' N C ` .Q
( Company Name %NV k C5 -.\-� (Phone) �-- , aJc� - Auz
(Contact Name) () _)(k- LikA t -k.e(\ .(L-S i (Phone)
(Address) \,6 S, S \`3 It e Ste' ACI 11)
TYPE OF WORK 0 New Construction ❑Beck DPorch e- Roofing DRe- Siding DLower Level Finish 0 Fireplace
DAddition DAlteration DUtility Conn ion
CODE: ❑LR.C. ❑LB.C. 0 Misc.
Type of Constriction: 1 II III IV V AB PROJECT COST /VALUE $
Occupan Group: A B E F HI MR S U (excluding land)
• 'sion: 1 2 3 4 5 ,
I here. . rti ` that I have h rni• - d informatio n this appli on 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 -m on d propel and t a all consn' c n will conform to . . isting state and Local laws and will proceed in accordance with submitted plans. I am aware that the building
official ca i evo e thi pe it for u cause F t' more, 1 hereby agree th he city ial s a designee may ente up n the property to perform cd inspections,
1 ) 116 s 4 ..40. ' 1 ” a IL,
I Signature Contractors 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 $ 79 75—
This Application Becomes Your Building Permit When Approved Paid / c Is eipt No. 6 703 /
Date �� 7-
Building 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 Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street Prior Lake, MN 55372
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