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,� O � CITY OF PRIOR LAKE BUILDING PERMIT, k.---, Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
l N" 5 k
PIO 1. white File PERMIT NO.
2. Pink City 377
3. Yellow Applicant io .
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) �_ s. fl Ck * r � _ (Phone) CM Q'�
(Address) U
BUILDER
(Company Name)B!''r '"\Cle( l er inleJ 'WW ') - (Phone) • g GS - 3 3
(Contact Name) b Il=sti' -- ,A. S _C_C ` ) (Phone)
(Address) 1 \ (0 (13 . Li 1- t 441 1 l) 1 --1 k -2-ibin ) l r b (1-4
TYPE OF WORK ❑ New Construction ❑Deck DPorch ❑Re- Roofing ❑' . ii . •• . -1 Finish ❑ Fireplace
['Addition ❑Alteration ['Utility Connection
CODE: DI.R.C. DLB.C. ' Misc: ) in(1 O di / A' .,
Type of Construction: I II III IV V A B
Occupancy Group: A B E F III M R S i 'ROJECT COST /VAL l - ' 60
Division: 1 2 3 4 5
I hereby certi that I h ave fun' formation on this applic r 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 do d pro rty and- . , ..emu: ion will confo to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official c rev ke th' hermit f. . ore, I he by a;. ee that the city official or a designee may enter upon the property to perform needed inspections.
igna " Contractor's License No. Date
Permit Valuation I _1 [pa Support Fee # $
Permit Fee
1 a I— 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 $ / O_
This Application Becomes Your Building Permit When Approved Paid 76. r/2,
Date S / /' / c)
Building Official Date
i
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 Data 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