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t.c. fPI% CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT �` . 3
~/41,NE I. white File PERMIT NO
2. Pink City t 3 3 - z)
3 Yellow Applicant t
(Please type or print and sign at bottom)
ADDRESS ZONING (of use)
33(02. 54 h ne r S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER —`' �—
(Name) J {) 4 1 (Phone) (/ 1 3CO3- -
(Address)
• BUILDER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK 0 New Construction Deck ❑Porch [Me- Roofing DRe- Siding DLower Level Finish 0 Fireplace
❑Addition ['Alter do ❑Utility Connection
CODE: 5_� LR.C. DLB.C. 0 Misc.
Type o c onstruction: I II III IV V AB 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 I have furnished inf rmation 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 prope at all constructs n 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 t . rmit fo Just c e , I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
x \ L c'
Signature Contractor's License No. Date
Permit Valuation 2 (..,.., _ Park Support Fee # $
Permit Fee $ 7 ? 7 - SAC # $
Plan Check Fee $ 41 CO. 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 $ (Z z , , 7
This A . 'ca , i Becomes Your Building Permit Whe ppr ved Paid (2Z . Z By Receipt (JL'J
Date . — F � `� ` y . '
limiek ate
This is to certify that t e redo 't in the above application and accompanying docume s is in ccordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the 7 ' P i r constitutes a temporary Certificate of Zoning comp ance a d allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
I- f i' �1 5
Planning Director D. e 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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