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0� PRlp� CITY
OF PRIOR LAKE BUILDING PERMIT, C Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
e AND UTILITY CONNECTION PERMIT
I. white File PERMIT NO. r, �1 7
4/jNi1/6So4h 2 Pink City
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
(9 // u ea n pci
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
7"--�-it,i a
(Name) kAye-- (Phone) /2_' ?I6 3S)(-33S)(-3
(Address) 67i° 4s?iZ ire/
BUILDER /, A (Phone)
(Company Name) /'C-4,-, 1�f t4C f,` �r .e"r_ (Phone) 1 -' yy7-(Contact Name) /�
(Address) [--7 6 //T lt-0t 1-- ` � E
TYPE OF WORK 0 New Construction ❑Deck ❑Porch ['Re-Roofing gte-Siding ❑Lower Level Finish 0 Fireplace
❑Addition ❑Alteration ['Utility Connection
0 Misc.
CODE: ❑I.R.C. ❑I.B.C.
Type of Construction: I II III IV V A B PROJECT COST/VALUE $
Occupancy Group: ABE F HI MR SU (excluding land)
Division: 1 2 3 4 5
�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 . •.etty 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 r • e thr per "r just cause more,I hereby agree that the city official ordesignee may enter upon the property to perform needed ln�Pect ��
R 'S Contractror's License No. Date
k Signature
Permit Valuation
Park Support Fee # $
Permit Fee
$ SAC # $
Plan Check Fee
$ Water Meter Size 5/8"; I"; $
$
State Surcharge $ Pressure Reducer
Penalty $ Sewer/Water Connection Fee # $
$ Water Tower Fee # $
Plumbing Permit Fee $
Mechanical Permit Fee $ Builder's Deposit
Sewer&Water Permit Fee $ Other $ 1 ,,
Gas Fireplace Permit Fee $ TOTAL DUE $ 79 75
No. -
Thi lication Becomes Your Building Permit When Approved Paid tig. `75- I RyReceipt '7Q�5c
Date / /
joy. . tD/ 6 / `
Building Official ate
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.
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