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CITY OF PRIOR LAKE BUILDING PERMIT, Date acid
E' . 1 TEM CERTIFICATE OF ZONING COMPLIANCE / /
c), AND UTILITY CONNECTION PERMIT
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. PERMIT NO.
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3. Yallow Applicant"
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(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
57o 2- Los 41:7{ -e i .e.I /;%'�; Gam - g. I 5 D
LEGAL DESCRIP'T`ION (office use only)
LOTL)( BLOCK 15 ADDITIONS 4 N ( I 'LA P1D ) 5 -- iv C
OWNER /1 l>
(Name) r97� 7V) . Lr1/4i�'i�/� f (Phone) (6)-oldCP- Ce a
( A d d r e s s ) 570-2 LGi s go a.) z t C /2L /C'/ SE, a G R 5537
BUILDER //�� /� f
(Company Name)i7�S4li r/r.S Xvr4.ch r es ei et /ih - (Phone) 9 S- - 1 - 7y5 V
(Contact Name) _ J t M 141. 4.4,--1 (Phone) el ' a °� / — S 516
(Address) 52 / S'7' S'r i0 3 i 7% 1 /1 6
TYPE OF WORK ❑ New Construction ['Deck ['Porch DRe-Roofing ORe- Siding ['Lower Level Finish ❑ Fireplace
[]Addition ['Alteration ['Utility Connection
CODE: OLR.C. DI.B.C. Misc: � l �n — , (,, g
Type of Constriction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ 1, 3 C O
Division: 1 2 3 4 5 (=lading land)
I hereby certify that I have furnished informant* , - . is to the best of my lmowledge true and correct. I also certify that I am the owner or authorized agent for the
above - mentioned property and that aJ,.ce3&u,. • : 1 .,... to 1 =g state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can this perm 1tstcan a gree that the city official or a designee may enter upon the property to perform needed inspections.
X a.---- Iw" s t3L 6'31 5 9 3
Signature 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 $ C
Gas Fireplace Permit Fee $ TOTAL DUE $
This Application Becomes Your Building Permit When Approved Paid ( U Receipt No. _____
6u )-D 09K) Date . st k: t 1 By 't )
Building Official Date
This , 1 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 _ • City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued. �.
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Pla®mg Directorr Da / SpecialConditions,ifany
24 hour notice for all inspections (952) 447 -9850, fns (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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