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of iE!11 / CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
A T E MPORARY AND CERTIFICATE UTILITY OF ZONING CONNECTION PERMIT COMPLIANCE / j
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40iNLSpCP 1. White foe
2 Pink City PERMIT NO. )3 f 2 ( I1
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3 Yellow Applicant
Please a or print and sign at bottom) ,
ADDRESS ZONING (office use) f S// y rner1rvi Tet S! 2.--
LEGAL DESCRIPTION (office use only)
LOT - ' C CK / ADDITION ( SI ` t � '' . .z 4✓z PID ' -00 i7 a3--(0
OWNER _
(Name) Pie/ 64I /F —rb (Phone) G 1 Z Z o z — 8Z rrl
(Address)
BUILDER f (Company Name) 'C" 3 C C1( e+ r S (Phone) tp / Z - -S / --5-7 Z !o
(Contact Name) eA o.k C4\ 1 (`i (Phone)
(Address) Z 3 0 Yo 2 k 4 r t k R.t
TYPE OF WORK 0 New Construction DDeck ❑Porch �Re- Roofing DRe- Siding DLower Level Finish 0 Fireplace
DAddition DAlteration ❑Utility Connection
CODE: DI.R.C. DLB.C. 0 Misc.
Type of Construction: I II III IV V AB sz
Occupancy Group: A B E F III MR 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 building
official can revoke this per ore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X ___ c BC 4 /5 1 94 1 Z/ //- /y ~/
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ (211. �� SAC # $
Plan Check Fee Water Meter Size 5/8 "; 1 "; $
State Surcharge $ 4- 67) Pressure Reducer $
Penalty $ L Sewer /Water Connection Fee # $
Plumbing Permit Fee Water Tower Fee # $
( l' Mechanical Permit Fee (r BuiIder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee [ $ TOT DUE / ' '7� ..,..,..4,
, 7 This Ap l ' '°n Bea: ((uud Yo ing Permit W hen Approved « 7D ? Receipt No. 0 •ate / / (/ /' , By
Ai .„.4. (/ . ,/ Z /3 i ' t 0 ,, ......,)
✓tu dine • fl Date
This fs to certify t 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.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -1245
4646 Dakota Street Prior Lake, MN 55372