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of PR/A, CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT eh ( !3
U t r j
41NNESOlt. 1. White File -
2. Pink City PERMIT NO. 2,13
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5'5 C re55an dfa 57z. 5A, pino
LEGAL DESCRIPTION (office use only) ) / '/
LOT BLOCK - ADDITION e /4,lt -L- f l d ° 2' / /4 6/Y PID 0975" i:2, 0300
OWNER L i s G. / " ! Q / no do (Phone) 4, / 219 V9- 6 3 6 3
(Name) (Address) 5 s s 3 C o 5 5o n d` a S- 5 E
BUILDER Pella Northland
(Company Name) (Phone) Q 5� 3 y G 7
15300 25th Ave N. Ste 100
(Contact Name) Plymouth, MN 55447 (one) J n C/i
(Address) Lic # BC645090 Ph. 763/745 -1400
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re- Roofing ❑Re- Siding ['Lower Level Finish ❑ Fireplace
['Addition ['Alteration ❑Utility Connection // 1
CODE: ❑I.R.C. ❑I.B.C.
1E1 Misc / CJ / 1/ C /u W ('I P / u Mal) -- / n 1 Y /J �/ o f
Type of Construction: I II HI IV V A B PROJ COS /VALUE $ / 0 G
Occupancy Group: A B E F H I M R S U t
(excluding land)
Division: 1 2 3 4 5 l
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that 1 am the owner or authorized agent for the
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
official can revoke this permit for it t use Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed mspe buns./ 3
3 !
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ ' Y r 75- SAC # $
Plan Check Fee $ 7 Water Meter Size 5/8 "; 1 "; $
State Surcharge $ O 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 $ TOTAL DUE $ 7g, 15_
This Application Become our Building Permit When Approved 116.11111M
!.1 � 111111MI Recei et No. es ., I
74 /1413 Date • 1 -- i •� By
in d i ial Date
1 %
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