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CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE .�
AND UTILITY CONNECTION PERMIT '"` ` S�
I. White Fie PERMIT NO. q 5-
2. Pink City 1
(Please 3 Yellow Applicant .,
type or print and sign at bottom)
ADDRESS
/� � j v� ZONING(office use)
�/o /Cn6./,Al //G, / �i
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID,5 -- 643 . 005-0
OWNER
(Name) c>.s'J 47U,n/Y7 (Phone)
(Address) /6 47/ '' ,�G,..,//.,ti /�,:, , / _5"-A"
BUILDER
(Company Name) i - t el'el. �•Q„,e (Phone) ey j,,7 734.
(Contact Name) / / S__.-..e03
(Phone)
,'
(Address) 77 /(1;cv7/` ',Cite $
TYPE OF WORK ❑New Construction Weck ❑Porch
❑Addition ❑Alteration ❑Utility Connection
❑Re-Roofing ❑Re-Siding ['Lower Level Finish ID Fireplace
CODE: C. ❑LB.C. 0 Misc.
Type of onstruction: I II III IV V A B
Occupan Group: A B E F H I M R S U PROJECT COST/VALUE $ /e.", .00
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 a . that all construction will con .rm to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can revoke this per,it for just cause. F . .rm.r ereby agree that the city official or a designee may enter upon the property to perform needed inspections.
Signature Contractor's License No. Date
Permit Valuation 3 ,, - Park Support Fee #
Permit Fee $ ge z — SAC
Plan Check Fee $ 573 Water Meter Size 5/8"; I";
$
State Surcharge $ Pressure Reducer
rls� $
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 D
This Appli/:ti. Becomes tour Building Permit n Appr ed Paid
�.. � ` Receipt No. 'j"
q - Date �� T By ROA •
/Iii
Buia�"eUtti_ �3 f�
Date
This is to certi that i quest in the above application and accompanying documents is in ccordanc ith the City Zoning Ordinance and may proceed as requested. This document
when signed by thhe ty 'anner cc. tutes a temporary Certificate of Zoning compliance d allows'onstruction to commence. Before occupancy,a Certificate of Occupancy must be
issued.
it, A . Z
A Pl.• mg . rate
Special Conditions,if any
24 hour notice for all insp tions(952)447-9850
4646 Dakota Street Prior Lake,MN 55372
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