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of PRI�rP CITY TEMPORARY OF
CERTIPRIORFICATE LAKE BUILDING
ZONING PERMIT,COMPLIANCE Date Rec'd
AND UTILITY CONNECTION PERMIT 7t 3 Q
atiA'NE 80iP I. White File
2. Pink City PERMIT NO. /5" Dm
`
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS /cis ccit / p4 A! ZONING(office use)
LEGAL DESCRIPTION(office use only) j
LOT /BLOCK DITION 1i 4 4. O/ PID 4J--- 7"�V�/�®2 -O
OWNER
(Name) r �S, � A (Phone) 7�—3c3 `�O 7
(Address)
BUILDER ' .
(Company Nam= A -/ .b`I A, (Phone) 76)-3ic'-j 071
Of ii
(Contact Name) `mom i (Phone) il�
(Address) l_� 0 'I 4 � f er gife-4/4-"' �)e)J C�
6
TYPE OF WORK ❑New Construction ['Deck ['Porch e-Roofing ❑Re-Siding ❑Lower Level Finish ❑Fireplace
❑Addition ['Alteration ❑Utility Conne ion
CODE: ❑I.R.C. ❑I.B.C. ❑Misc.
Type of Construction: I II III IV V A B PROJECT COST/VALUE $ Ger✓
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 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 a this permit for just cause. Furthermore,I hereby agree that the city official a designee may enter upon the property to perform needed ins ecton .
Signature Contractor's License No. to
Permit Valuation Park Support Fee # $
Permit Fee $ ` SAC ## $
Plan Check Fee $ 7 Water Meter Size 5/8"; I"; $
State Surcharge $ 1� „ 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 $ /aft, I
5/
This Application Becomes Your Building Permit When Approved Pai i* c17 Receipt No. -2._
Date By
Building Official Date I (-23O • 1S
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
4646 Dakota Street Prior Lake,MN 55372