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04 PR/04,
CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
1 TEMPORARY CERTIFICATE OF ZONING COMPLIANCE 6 > / �
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AND UTILITY CONNECTION PERMIT / !l7
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2 r rata tea P ERMIT NO. fa r 0 J
rink File (O
3. yellow Applicant
(Please type or print and slyaat bottom)
ADDRESS / E J � ) Zi office use)
I / R) s /lr / -� i ie/ 1
LEGAL DESCRIPTION (office use only) 0 t
LOT BLOCK 1 ADDITION 0 ere V `T(& 6 6 PID 075'-. 3 (U - 0 Ce% 6
OWNER - � I ' (( C �jj 1
(Name) / l YN L�bi n t_
' ,i3 e'S( £N (Phone) 9 -eR ` ! 3- ?3 47
(Address) s�T kr? E___.
BUILDER ` t (Phone) 88g .- S`�.
(Company Name) �141�c° /n�d l,�S VAC. Phone ) 9
(Contact Name) - e All - ( (Phone) �'J 3> 9 - &.5 1 r
(Address) %O/ C /3lao/I1(H q f .+v J�P / .�. / sTL / �Vi 0') 0701 //' V Job b ,
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch (ate - Rooting ❑ire Siding ['Lower Level finish ❑ fireplace
❑Addition ❑Alteration ['Utility Correction
COVE: 01.R.C. D.B.C. ❑ }disc: •
Type of Construction: I LI III IV V A B i d
Occupancy Group: A B E F 11 I M R S U PROJECT COST /VALUE S 1, s
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 - 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 just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X . _ 13c._ 1 -f`1 .30L,, s -a.. -) 3
Signature Contractor's License Imo. Date
Permit Valuation Park Support Fee # S
Permit Fee $ //�■ 7 S'' SAC # S
Plan Check Fee $ ! Water Meter Size 5/8"; I"; S
State Surcharge $ 5, 0 GI Pressure Reducer S
Penalty $ Sewer /Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit S
Sewer & Water Permit Fee ' S Other $
Gas Fireplace Permit Fee S TOTAL DUE $
.1 4
This Application Becomes Your Building Perini to i When pproved ,a,-,111111111111161111" Recei a t No, 1131111111100111 !- O 1-, Date �- .el - z „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 proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Berme 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 -4243
4646 Dakota Street S.E., Prior Lake, Minnesota 55372