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o4PR.ts CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd •
A, e TEMPORARY CERTIFICATE OF ZONING COMPLIANCE /
AND UTILITY CONNECTION PERMIT ' 1 t `/
7K........._ �,
r� o,��. I• white File PERMIT NO. 4
NES 2. Pink City i `../ �JQ
3 Yellow Applicant (0
(Please type or print and sign at bottom)
ADDRESS / ZONING office use)
/SO3/ /,'/S Ass ///p/ ,4°, , hie. 1�,(�
..
LEGAL DESCRIPTION(office use only)
2 J (r.1('-.S2N� 2p_d
LOT (BLOCK / ADDITION e AUN PID W5-- ��I�
OWNER '7 p� /
(Name) £c, iic �2(Phone) (Q - O Q5(O/�/
(Address) /5-o3/ ilnv-J / "' ci A/w, /r/ `�l'�l p- e.
BUILDER
(Company Name) (Phone)
t 0
(Contact Name) (Phone)
(Address) f
TYPE OF WORK 0 New Construction ?SJDeck ❑Porch ORe-Roofing ❑Re-Siding ❑Lower Level Finish 0 Fireplace
❑Addition DAltera ion ❑Utility Connection
CODE: R.C. ❑I.B.C. 0 Misc.
7
Type ofEstruction: I II III IV V A B PROJECT COST/VALUE $ 2 5-44 D o
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 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 rev e t ' for Just cause. Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X7_1-2 / /
Signature Contractor's License No. Date
Permit Valuation ifa5ri/ Park Support Fee # $
Permit Fee $ p g. Z 5 SAC # $
Plan Check Fee $ s-1 .3 G Water Meter Size 5/8"; 1"; $
State Surcharge $ I , ,� Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer&Water Permit Fee I $ Other $
Gas Fireplace Permit Fee I $ TOTAL DUE $ �41.-\• \\
This Ap•!cat'on : •Im. -i our Building Permit en A• , oved Paid ' . ` Receipt No. �' (i L,\ 1
%; / � Date If 1 ( Byit iit—
Building Official Dat
This is to cert; tha the request in the above application and accompanying documen.is in cordance with the City Zoning Ordinance and may proceed as requested. This document
when signed he i Planner constitutes a temporary Certificate of Zoning comp(i ace a .allows construction to commence. Before occupancy,a Certificate of Occulancy must be
issued. iI I
1 4
+,:1 • . Directo D.e Special Conditions,if any
24 hour notice for all i spections(952)447-9850,fax(952)447-4245
4646 Dakota Street Prior Lake,MN 55372
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