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( -74- 4..f PRCITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
o TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
m AND UTILITY CONNECTION PERMIT l6., ,7„, /
1IN"splP I. White File
City z rPERMIT NO. �7
0v3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESSZ G(office use)
/e-i-e, e'4/2(24/-Azeia2.25,Z
LEGAL DESCRIPTION(office use only)/�' l��/4
LOT BLOCK ADDITIONI�`'„/ /1e,��'C z,SL`�lQ '1)(15;5 PID 5i� �—O77
OWNER '�
(Name) /-- Z _ (Phone) 6/2 ` / ®/ 3
(Address)
BUILDER
(Company Name) (Phone)
(
(Contact Name) v (Phone)
(Address)
TYPE OF WORK ❑New Construction ['Deck ['Porch Re-Roofing ❑Re-Siding ['Lower Level Finish ❑Fireplace
['Addition DAlteration ['Utility ConnctE iotT
CODE: ❑I.R.C. ❑I.B.C. ❑Misc.
Type of Construction: I II III IV V A B •
PROJECT COST/VALUE $
Occupancy Group: A B E F H I M R SU (excluding land)
Division: 1 2 3 4 5
I hereby certify th ave 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-mention pro er and that 11 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 oke th. rnit for jus Ise. Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
AO Of.
(1) ' /7 /V
SignatureContractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ --....-- SAC # $
Plan Check Fee $ /1/ 5 Water Meter Size 5/8"; 1"; $
State Surcharge $ Reducer $
Penalty $ ` Sewer/Water Connection Fee # $
Plumbing Permit Fee $ ,P----L-----'n
Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer&Water Permit Fee $ Other $
,79'.. iGas Fireplace Permit Fee $ TOTAL DUE $
w
This Application Becomes Your Building Permit When Approved r.1 a ( "l ` Receipt No. 1 Z jfil
Date10 91 / By
r1 (-( ,
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