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Jul. 11. 2011 3: 54PM No. 0908 P. 8
of 1 CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
fa AND UTILITY CONNECTION PERMIT
fa i'OrNE•Ot" I. White
K ` i t PERMIT NO J/ ` � ' n
a. vise City ! / ' „ .. Yellow Applicant lf/
(Please type or print and sign at bottom)
- - _
ADDRESS ZONING tamceusc)
1 1o13' Lit( tn { I�Oa. d ..
• •
LEGAL DESCRIPTION (oflicc use only)
•
LOT BLOCK ADDITION PID •
OWNER G C p
( N ame) lX [..e �' S Q 1/� (Phone) 1 41 D 6 1 Ce 6
(Address) U_ R 90 J �.
BUILDER V0v t 0 6152-497-3K12
(Company Name) Ali OW y i .. t (Phon
1
(Contact Name) i a r(US -r , (Phone) _
(Address) J 01(1 All t NA t Iv
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch FRe•Roofing ❑Rc.Siding ['Lower Level Finish ❑ Fireplace
['Addition ['Alteration . ❑Utility Connects n
CODE: .DI.R.C. ❑I.B.C. ❑ Misc. p,1
Type of Construction: I II III IV V A B
PROJECT COST /VALUE S G v
I 0 J ' 1) b
Occupancy Group: A B E F Iii X M R S U
Division: 1 2 3 4 5 (excluding land)
1 hereby certify that 1 have Pomished information on dhtr 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 - mentioned property and that all C011SlrucIIo11 will conform to all existing stare and local laws and will proceed in accordance 'with submitted plans. 1 am aware Mee the building
official , e that it for just cause. Furthermore 1 hereby agree that the city officiator a designee may enter upon the property to perform needed inspections.
X y 1 r 10(032. tS E Sr (I r I 1
Signature Contractor's License No. • Date
•
Permit Valuation Park Support Fee # S
Permit Fee $ SAC # • $
Plan Check Fee $ ' Water Meter. Size 5/8 "; 1"; $
State Surcharge S Pressure Reducer $
•
Penalty $ Sewer /Water Connection Pee # ' $
Plumbing Permit Fee $ Watcr Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $ /
Sewer & Water Permit Fee $ Other ` $
Gas Fireplace Permit Fee $ TOTAL DUE ^ S >
0 6
Thls Application Becomes Your Building Permit When Approved Paid (/ Receipt No.
bate /) ,II 1 t B,y
l/ J
thiildina Oflicihl Dntc
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 rv This document
When signed by the City Planner constitutes a tenlpurary Certificate of Zoning compliance and allows construction to commence. Berne occupancy, a Certificate of occupancy mUSI be
issued.
Planning Direclor Data Special Conditions, if any
24 hour notice for all Inspections (952) 447.9850, fax (952) 4474245
4646 Dakota Street Prior Lake, MN 55372