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.a, \�' CITY OF PRIOR LAKE BUILDING Mcd
W; TEMPORARY CERTIFICATE OF ZONING COMPLIANPERIT i
CE Date Re
AND UTILITY CONNECTION PERMIT /1'w g. , /3
k.white File
2. Pink I PERMIT NO. 3 `�
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(Please type or print and sign at bottom) 3.Yellow Applicant
ADDRESS
N2s- atiwke3) � ZONING(office use)
LEGAL DESCRIPTION(office use only)
•
LOT q BLOCK / ADDITION / /)s/`'I /l N PID /45'.2. 5=05
(ONaWNER /�/ (n n AV-. _
F— (Phone) ?5-2,-- q7
(Address) /446 C 1 d LaLILI �v',r f l.�-�--�" G"' '3(7.2__� -
/
BUILDER //
(Company Name) DuBois Design&Remodeling,Inc. (Phone) (.eS1- 6- oeLiq
(Contact Name) 11825 Point Douglas Drive South
v',1
t VI AL t' b (Phone) (CSi - `fSS - D e qq
(Address) Hastings,MN 55033
TYPE OF WORK 0 New Construction ['Deck ❑Porch
❑Re-Roofing ARe-Siding ❑Lower Level Finish 0 Fireplace
DAddition DAlteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. �y, (,Yt;
Type of Construction: I II III IV V AB
/`t'Misc: v r�
Occupancy Group: ABE F HI MR SU PROJECT COST/VALUE $ ') (/7UL' a"
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 ris rmait for just cause. I hereby agree that the city official or a designee may enter upon the property to perform needed/3Ji
ec .
% revo
W\" ' ocj?gb <
Signature Contractor's License No.
Permit Valuation ..10?4,,7 0 d Park Support Fee #
Permit Fee $ CD SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1";
State Surcharge $ S' d O 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
This Application Becomes our B •'ding Permit When Approve r
. 149..._. 1s--‘k`SD Receipt No. 110/ 0 ,
q--, r. . .....-N_ Date p) I By / I
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 S.E.,Prior Lake,Minnesota 55372