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TEMPORARY CITY OFCERTPRIORIFICATLAKEE OF BUILDINGZONING PERMITCOMPLIANCE, 1/ Date Rec'd
U AND UTILITY CONNECTION PERMIT
rkNEs� $$—tq .-15
1. wrote File I PERMIT NO. ' .-�// I
z. Peck city / !/
+ (Please type or print and sign at bottom) 3.Yellow Applicant (`.r��
ADDRESS
ZONING(office use)
17103 Sunrise Ave. Prior Lake, MN 55372
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Name)OWNER Jeff/LeAnn Jorgenson 952-447-8603
(Phone)
(Address) 17103 Sunrise Ave. Prior Lake, MN 55372
BUILDER Custom Remodelers, Inc.
(Company Name) (651)784-2646
Karli Anderson (Phone)
(Contact Name (651)784-2646
(Phone)
(Address) 474 Apollo Drive. Lino Lakes, MN 55014
TYPE OF WORK 0 New Construction [Peck ['Porch ORe-Roofing ['Re-Siding ['Lower Level Finish 0 Fireplace
• ['Addition ['Alteration ['Utility Connection
' CODE: DI.R.C. ❑I.B.C. DMisc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ $'500'00
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have furnished informatio ..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-men oned property and at all construction • conform to all existingstate and local laws and will
official oke this. , proceedntin the property with submitted plans. I am aware that the building
ust ca Furtherm� e,I hereby agree that the city official or a designee may enter upon the to perform needed inspections.
X 1 / /' CR001748 June 9th 2015
Signa e Contractor's License No. Date
Permit Valuation Park Support Fee ## $
Permit Fee $ SAC ## $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
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 $
This Application Becomes Your Building Permit When Approved I Paid l 0- ) .--/5"- Receipt No. /Cp Y
t Date `7 ?_ I By x/17 Lf.
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