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of PRioR CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
4. 4�ANEScoP TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT /L-yl o
0I. White File
2. Pink City PERMIT NO./5Z
5Z 1/ -�
(Please type or print and sign at bottom),C��/Z o ,/ Yellow Applica n
.ADDRESS � `�
�( c 0e,
ZONING(office use)
Pr
) - 5 7y
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
rteOWNER R\C-fill(Name) ) (Phone) '--)
3
(Address)
BUILDER
(Company Name) �� t e'/L/ VtOG4°
(Phone) i ' "'CriXe_
(Contact Name)
(Phone)
(Address)
TYPE OF'WORK 0 New Construction ❑Deck ❑Porch e-Roofing
❑Alteration g ❑Re-Siding ❑Lower Level Finish 0 Fireplace
❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. 0 Misc.
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R SU PROJECT COST/VALUE $
Division: 1 2 3 4 5 (excluding land)
I
I hereby certify that I e furnished informatio 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 pro. and that all construe is will conf rm to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can revoke till' .ermit for) st calls Fu t•er•ore,I hr4eby agree that the city offuc' or a designee may enter upon the property to perform needed in .ectio -.
f 7 Signature
Contractor's License No. sate
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 # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer&Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $ vls--
This Application Becomes Your Building Permit When Approved Paid 1 C . 7
/, R eipt No.
Date ll . ,tfr,,tom-% B , /,
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.
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