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s,F PR/of CITY OF PRIOR LAKE BUILDING PERMIT,
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TEMPORARY CERTIFICATE OF ZONING COMPLIANCE Datt
AND UTILITY CONNECTION PERMIT
44 * ESO S �
I. White Pile I P ERMIT NO.
2. Pink Pity
(Please type or print and sign at bottom) 3 Yellow Applicant i Z . / 1 .-
ADDRESS
4-1 f � � / - ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER ,�
(Name) e )-- .1 - 'V
(Phone)
(Address) / Y7/2 'Z, e- Z
BUILDER ,�
(Company Name) J � 5, ) 6 ' i * ,6' 7! � j
//:., (Phone) Lj
(Contact Name) C v•.)
(Phone) 5//'■
(Address) '7 W9' ,4)49 5z/ ,q ii �
TYPE OF WORK ❑ New Construction ❑Deck
D Alteration ❑Uti Connection Roofing ❑Re- Siding ❑Lower Level Finish 0 Fireplace
❑Addition �,
CODE: I.R.C. ❑I.B.C. ❑ Misc.
Type of struction: I II III IV V A B�j
Occupancy Group:
`"
P cY p: A B E F H I M R S U PROJECT COST /VALUE $ Z
Division: 1 2 3 4 5 (excluding land)
I 1 hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. 1 also certify that 1 am the owner or authorized agent for the
1 above - mentioned property and that 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
4x AK Api-a441 • official ca. revoke this rmit for just cause. Furthe . . c, I her• . :r • that the city official or a designee may enter upon the properly to perform needed inspections_
,.� % � `�
Signature 7X A
Contractor's License No. mate
Permit Valuation
Z O Q — Park Support Fee # $
Permit Fee $
1 4' SAC # $
Plan Check Fee $
�
Water Meter Size 5/8 "; 1 "; $
State Surcharge ' $
c� -- 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 I $
TOTAL DUE $
This Appli tit n : ecomes Your Building Permit When i• ppr ved
J / Paid � Receipt No.
�' Date I
Buidd -- s ate
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,
issued. y proceed , a as a c of requested. This document
must b
p. y, a Certificate of Occupancy must be
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