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PRIG
U CITY OF PRIOR LAKE BUILDING PERMIT Date Recd
° TEMPORARY CERTIFICATE OF ZONING COMPLIANCE y t 1
AND UTILITY CONNECTION PERMIT
M'A'NESO29 2. Pin'ke File PERMIT NO.
zi
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 H2O Gwi, °,./ A i j _ 7'r S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 4 /
(Name) X ni i / rn X. S (Phone) 6/1 ) c) / - ii Sr 5 ,
(Address)
BUILDER / /
(Company Name) / 1, /tn o (2 1 .�[ 5-4_26, 5 (Phone) 7 C 3 G' /) /S 8
(Contact Name) 1/ Z (Phone) G 0-- 73S 7-
(Address) 5 r( at, e G." s Pv - tic--- a 75 . 0 , /-t ." 4 - s -33 c.)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ERe-Roofing ❑Re- Siding ELower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
?�i. O CODE: ❑I.R.C. ❑I.B.C. )Misc. ( 2) O ofe__S
Type of Construction: I II MTV V AB
Occupancy Group: A B E F HI MR S U PROJECT COST /VALUE $
(excluding land)
Division: 1 2 3 4 5
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 a : "? 'irru • on will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
offici. . - .. .ermit for just cause. u °••.• e, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
x 1��� 2 v s g• / 3 4>5 4 / 7._ 1/
Sign. . -- Contractor's License No. Date
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 / $ 7 9 7
! �
This Application Becomes Your Building Permit When Approved Paid i i.t No.
Date - - / B
Building Official Date
if •
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