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of r xIO CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
e c TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT / 2 /. a
l
t. White File
2. Pink City PERMIT NO /3 S /0
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
35 5 erI.ie T S,t.J
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) TQ )< a d' r• (Phone) C± 1 L\ L `i 0 1 3 411
(Address) 3 3o S r e. s qr,r" \ 5. w•
BUILDER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK D New Construction 0Deck DPorch Ke- Roofing DRe- Siding ,Lower Level Finish 0 Fireplace
DAddition DAlteration DUtility Connection
CODE: DI.R.C. DI.B.C. 0 Misc: - 7
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST /VALUE
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have furnished information 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 property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildin
official can revoke this 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 $ 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 $
Gas Fireplace Permit Fee $ TOTAL DUE . $ /
This Application Becomes Your Building Permit When Approved Paid l 9' 1 R eipt No. 9S
Date 7., Z (I?
Building Official Date
This 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 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.