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o f PI CITY OF PRIOR LAKE 11 UILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE Date Recd
AND UTILITY CONNECTION PERMIT
��NNE50
I. White File P ERMIT NO. f ) / 6 I
3 pe City / L �J�
(Please .e or .tint and si: at bottom) 3 Yellow Applicant
ADDRESS
ZONING (office use)
l 5 S (.../ - rot7
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER
(Name) > U r S +o / ll-
(Phone)
(Address)
BUILDER
(Company Name) fl
l �C'� (�
(Contact Name) (Phone)
(Address) �(� s() �,�/ (Phone) �� SA- ` �/� " 1l
TYPE OF WORK 0 New Construction ['Deck
❑Porch e- Roofing
DRe- Siding ❑Lower Level Finish
['Alteration DUtility Con tio ❑Fireplace
CODE: ❑ I.R.C. ❑ I.B.C.
❑ Misc.
Type of Construction:
DAddition I II III IV V A B
O ccupancy G roup: A B E F H I M R S U PROJECT COST /VALUE $
Division: 1 2 3 4 5 (excluding land)
I 1 hereby - mencertiftiy that 1 have hirnished in formation on this applicatio which is to the best of my knowledge true and correct. 1 also certify that 1 am the owner or authorized agent for the
a l
p rop erty and tha all co ns t ruc t ion will conform to all existing state and local laws and will proceed in accordance with submitted plans. 1 am aware that the building
I X nacittei„.—....) 1‘e
o c an revoke t permit for)ust cause Further r e, f h ere by agree t t he city o or a des may enter upon t property to perfor needed inspections.
I 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 $
79 -75
This Application Becomes Your Building Permit When Approved /
Paid �n Recei.t o 1 ! ' -
Date B - ' 1A AWI
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
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 y proceed as requested. This document
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