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o f Pi% CITY OF PRIOR LAKE BUILDING PERMIT, Date c'
A. " TEMPORARY CERTIFICATE OF ZONING COMPLIANCE g .
AND UTILITY CONNECTION PERMIT
� �
AI' 'HHeso x° I White File
? Pink City /J . PERMIT NO. , Syo
.
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 Y 9 /4 k A J-? /OF 7 v sisa
LEGAL DESCRIPTION (office use only)
LOT LOCK F ADDITION 5, J j P 11 /4 PID R5 - 2os - O7'-
OWNER OWNER ,
Phone ) 6 7 4 � 6 3-C
(Name) ,5 A.,,, � �� 4_,,A, ( l
(Address)
BUILDER
(Company Name) i3 rte ck( R C) 6 (Phone) , S a- a - 2C0 ----, 11 a
(Contact Name) 1 .) (Phone)
(Address) /,5--7 g 4,, t ,I,_,,r1 j _(�
TYPE OF WORK 0 New Construction OD ck ❑Porch e - Roofing ORe- Siding OLower Level Finish 0 Fireplace
❑Addition OAlteration ❑Utility Connection
CODE: DI.R.C. DI.B.C. 0 Misc. c�
Type of Construction: I II III IV V A B PROJECT COST /VALUE $ , / ■ &O )
Occupancy Group: A B E F HI MR S U (excluding land)
Division: 1 2 3 4 5
t
I hereby certify that I have furnished information on this application which is t '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 exist' state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can revoke • permit for just cause • rmore, 1 hereby agr e - th the city official or a designee may enter upon the property to perform needed Inspections.
x if �� -V� ( ` 7C -I
Signature Contractor's License No. Date
Permit Valuat • Park Support Fee # $
Permit Fee $ S f ' / .. !7 SAC # $
Plan Check Fee $ _ / Water Meter Size 5/8 "; 1 "; $
State Surcharge $ 57:0/ti V 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 $ �} 9 IS TOTAL DUE _�_`
/
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This Application Becomes You : uilding Permit en Ap oved an M' Recei. t No. �%i��
Date
Buildim, 4 fticiai Date
This is to certify tha 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) 4474245
4646 Dakota Street Prior Lake, MN 55372