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OF r1110 CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
A. ` TEMPORAATE ONI COMPLIANCE
v , AND RY UTILITY
CONNEC T PE RMIT
PERMIT NO. y � f
Yellow Applicant /,.: � / , 4'kNE SO
ease type or print and sign at bottom)
ADDRESS '7 ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) riIA An r Ugh p I (Phone) - 1 i 7 - Y f ( 6 - -2 9 /1
(Address) 1 yq 5 ) 0.11cf Y1 I e.o'd 1\3 6 Pr 16 r L.Le / (/� /U Q.S 3 7
BUILDER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
Jis TYPE OF WORK EJ New Construction ❑Deck ❑Porch ❑Re- Roofing ,e- Siding El Lower Level Finish ❑ Fireplace
❑Addition DAlteration ❑Utility Connection
CODE: ❑LR.C. ❑LB.C. ❑ Misc.
Type of Construction: I II III IV V AB PROJECT COST /VALUE $
ccupancy Group: A B E F H I M R S U (excluding land)
ivision: 1 2 3 4 5
I hereby certi that t ave rnished infor ti on on this application which • the of knowledge u a n o t. Its c• 6f at 1 am th • owner ur authorized agent y ty ,4( t o pp his to e best e my true and correct. also o u y that � m E t c ent f the
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above- mentioned p pet . d t all co struction 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 revok his , ■ it or j ca e Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections
ll
X 9 - i9_ 7 o rz
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8 "; I"; $
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 I $ TOTAL DUE $ 79 7c"
This Application Becomes Your Building Permit When Approved Paid /q. 7 i) Receipt No l,- 7L L)
Date 001 By 1■10.€ , .2
Building Official Date
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
hen 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
¶ h!s
sued
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
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