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o p TEMPORARY CERTIFICATE OF ZONING COMPLIANCE Q��7 AND UTILITY CONNECTION PERMIT °/
4 /NNESdS' I. white File
2. Pink City PERMIT NO. I og /k
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS C- / ZON (office use) ./.
' 4 0 l 7 Ca......., d,...., Ct., LEGAL DESCRIPTION (office use only)
L BL ADDITIO(/ O4 ki 2 /V I/ PID Z.
OWNER - ( t ('� ' ®� Z - 6
(Name) 1 � t't 1 r f v� l`
l (Phone) l�
(Address) ( ((V /7 cc,--,_v.e c vt t/.
BUILDER ,
(Company Name) r
✓S ? h�r�f�`[� ~� Z (Phone) 9 - S - . ) -- - Z3 7'U $Z 0
(Contact Name) r--c- '.a(az". (Phone)
(Address)
TYPE OF WORK ❑ New Construction DDeck DPorch )rtiRe- Roofing DRe- Siding ['Lower Level Finish ❑ Fireplace
❑Addition DAlteration ❑Utility Connectio
CODE: DI.R.C. DI.B.C. ❑ Misc.
Type of Construction: I II HI IV V A B PROJECT COST /VALUE $
Occupancy Group: A B E F HI MR S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that . ave furnished information on this application which is to the best of my knowledge true and correct. I also certify that 1 am the owner or authorized agent for the
above- mentioned-pro. -try and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. f am aware that the building
official can rev , e permit for Just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ if / / 75 SAC # $
Plan Check Fee $ ! Water Meter Size 5/8 "; 1 "; $
State Surcharge $
5;06 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 $ ` r 25-
This Application Becomes Your Building Permit ' en ' . proved t ' Receipt No. l _
i ti l r D to By
: adding li Date
This is to certify at t test in the above application and accompanying
h' q pp 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