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ACITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
EA, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ^f 6rl
11 —... x
AND UTILITY CONNECTION PERMIT
v
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1111/114,141e 2I r n'ke A Y PERMIT NO. �
3 Yellow Applicant 1.-__I `.
(Please type or print and sign at bottom)
ADDRESSZONING(office use)
NG7 ? T-y - 'Er' liE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID "aC1
OWNE)R, J_✓(�� S6'4- ( 1 ' ( ) �js (~ laS-Q��? 7
' Phone
(Address)
BUILDER (� ( C"^-43/741-14")
�� /' / t,/
(Company Name) 3JA-`�� C'^ � �S4 (Phone) V` k ci ( ��
(Contact Name) 4 Iiy�'ry.......Nt o"'` (Phone) l
(Address) 5-3 3 `T /$ 1.-1 /7%,"V--- S
TYPE OF WORK ❑New Construction ❑Deck ['Porch ❑Re-Roofing Me-Siding ❑Lower Level Finish ❑Fireplace
['Addition ['Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑Misc. / /�iyf
Type of Construction: I II III IV V A B PROJECT COST/VALUE $ —/,et •
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that I have burnished 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 r oke thi ermit f r lust ca Furthermore,I hereby agree that the city official ora designee may enter upon the property to perform needed inspections.
X 6 51 ?.1 `f • (fir
tgnatur Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ 7 4/.75
SAC # $
Plan Check Fee $ Water Meter Size 5/8"; I"; $
State Surcharge $ Pressure Reducer $
Penalty $ Q Sewer/Water Connection Fee # $
Plumbing Permit Fee $ '�i
/ 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 7.7' Receipt No. �f Z1
Date fv-1rj By `--� !
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. T its 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