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CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEAL TH AND SAFETYI
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CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
1. White
2. Pink
3. Yellow
File
City
Applicant
_+_~" .~ ___ .....__.... __......_._,. I.
Permit No. C\ ~ - 3:. L.3..
DIREcnONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
167<6 f.,U~
1. DATE
10/1
?
BUILDING INFORMAnON
11. SIZE OF STRUCTURE
(Helltrtl (WIdth) (Depth)
3. LEGAL DESCRIPTION / J
LOT Y BLOCK-::t-
L-l )-A JL-u~ It' ~
PID ~:.r: ~/3 - ()OJ. 7-0
, I
12. NO. OF STORIES
~
13. TYPE OF CONSTRUCTION
ADDITION
5. ARCHITECT (Name)
c;.1t. F-
6. BUILDER (Name)
S"tt p
7. TYPE OF WORK Fireplace 0
New Construction 0 Alterations 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq.Ft.
(Name)
(Address)
(Tel. No.)
14. FLOOR AREA APPORTIONMENT USE
4. OWNER
(Address)
Septic 0
Addition 0
Heating 0 Plumbing 0
Finish Attic 0 Residing 0
Reroofing 0 Porch 0
Finish BasememD-(
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
SEATS
16. ESTIMAT:HV~UE
". ';,.CJOO
17. COMPLETION DATE
/2/?1 Ie.
(Address)
(Tel. No.)
9. PROPERTY DIMENSIONS
Width Depth
10. CULVERT SIZE
Yes No
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and oorrect. 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 thatlhe
building 0 . aI can revok is ermit r Just . Furthermore, I hereby agree that the city offIclaI or , l.esIgnee may enter upon the property to perform needfd inspections.
X 1" \A. LJcense No. J 0 I..tle 9' .3
FOR ADMINISTRATIVE USE
Front
Back
SIde
Side
MATERIAL FILED WITH APPUCATION
SOIL TESTS 0 ENERGY DATA 0
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS ~ SETS
SURVEY 0 COPIES
z..
SETBACKS: Required
Actual
PROPOSED GRADE FOUNDATION
IN RELATION TO CURB OR CROWN
OF STREET
USE OF BUILDING T? } ""'-" A.A.':;;"~+ ~.".,.~
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
.fie--
---.J ..
~D~
PLOT PLAN 0
TYPE OF CONSTRUCTION: I II III IV fD
Occupancy Group A BEl H(B)M
Division 1 2(!)l
Permit Fee ................................... $
City:
Amount Brought Forward . .. . .............. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
SewerTap ................................... $
Ucanse Check Fee ......................... $
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
o Sewer & Water Connection Fee ........... $
o Water Tower Fee ........................... $
/2 '. ~~
Plan Checking Fee ......................... $
State Surcharge............................. $
(d. 00.
.itCo, ~~
2 f :C.~
Penalty ....................................... $
Septic System ............................... $
Other ......................................... $
By
Water Tap ...... .......... ...... ....... ...... $
Other ......................................... $
Other ......................................... $
Total Due .............................. $
Paid I.' 0
Date'{) - B
request in the above application and accompanying documents Is In accordance with the City Zoning Ordinance and may proceed as r ed. This document when
Ianner constitutes a ~ Certificate of Zoning complJanoe and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued.
l --.. I ~- (.". -<;~
City Planner Dale Special Conditions W any
24 Hour notice for all inspections 447-42309:00 a.m. .10:00 a.m.
/.1/, 3>~
Check if
Deferred
es Your Building Permit When Approved.
Date (~- b-C;~
Certificate of Occupancy
Issued
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF
APPLICANT A~~ ~--'
/~~/93
APPLICATION RECEIVED
The City of Prior Lake BUILDING Department has reviewed the
building permit appl~cation for construction activity located at
/~7,pF Lu~W~y~ .
Acc~Pted . .f~ied
ReVlewed by: ~\~
Comments : ~t~J_ -~
Accepted with Corrections ~
Date I (~ - (..=-S--:s.
~~ ~~,...:{\ ):;""'~ .:::..'_ lr.fJ'"~ca.$
"The issuance or granting of a permit or approval of plans,
specifications and computations shall not be construed to be a
permit for, or an approval of, any violation of any of the
provisions of this code or of any other ordinance of the
jurisdiction. Permits presuming to give authority to violate or
cancel the provisions of this code or other ordinances of the
jurisdiction shall not be valid."