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ITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
/ AN.,c TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT e l. / Z
r kiv E 5
1. Pink City PER NO.
2. Pink City J /
3. Yellow Applicant J
(Please type or print and sign at bottom)
ADD SS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION MID to
(Name) ER ( t-LC- �0 i c r l e (Phone) G
(Address) 1 4-13! 2,-- l _.` 46, 'c s ` /ii,,,K' 7
BUILDER 4 , (Company Name) 5C 144 ( "�' 1 '" l 00,1 ljZ C �L` / �'
(Phone) / �3 Q
(Contact Name) Ccu t tom" 1 t "� _ (Phone) (o J ( L c1$ G` C
(Address) y 0 raA,` 4Y lL d c )
TYPE OF WORK ❑ New Construction ❑Deck ['Porch giRe- Roofing ❑Re- Siding ['Lower Level Finish ❑ Fireplace
['Addition ❑Alteration ['Utility Connection N ^ ( l
CODE: ❑I.R.C. ❑I.B.C. ❑Misc: ( '(�' -G,14- -I' 1 f 29 Vt6t r 4�d!� C /�41
uc
Type of Construction: I II III 1V V A B i/ t/ )
Occupancy Group: A B E F HI MR S U PROJECT COST /VALUE $
Division: 1 2 3 4 5 (excluding land)
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 I am the owner or authorized agent for the
above- mentioncdlroperty 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 rt;ztoke this pernnct for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed ins - ctio .
x 7C i 7 - 7 5 c
Signature Contractor's License No. it ate
i
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 � $
Permit This Application Becomes Your Building Peit When Approved Paid 7 Rec ' No. ' 3 /(P
Date `5 . ee , L,... B
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 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 S.E., Prior Lake, Minnesota 55372