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Date Rec' d
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
n at bottom)
4&79
TOWe~
7, 14, (j~
1 White
Pink
Yellow
I PERMIT NO.a,. o~51
File
City
Applicant
ZONING (ortice use)
.5T/U3eT
LEGAL DESCRIPTION (otftce use only)
LOT
BLOCK
ADDITION
PID
OWNER
(N ame)
(Phone)
(Address)
BUILDER
(Company Name)
(Contact Name)
(Address)
L-/9/Jc.6 OtJ!GN
(Phone)
(Phone)
ORe-Siding OLower Level Finish 0 Fireplace
TYPE OF WORK 0 New Construction ODeck OPorch ORe-Roofing
OAddition o Alteration o Utility ConnectIon
CODE: OI.R.C. OI.B.C. )ef Mise
Type of Constmction: I II III IV V A B
Occupancy Group: A B E F H I M R S U
Division: I 2 3 4 5
5Cj/26S:S WIA/OtJvV
PROJECT COST IV ALUE $
(excluding land)
I hneby cntIty that I have turmshed Information on this apphcatlOn which IS to the best of my knowledge true and correct I also certify that I am the owner or authonzed agent t'lr the
,lbove~mentlOned properry 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
offici"l can revoke tillS permIt Illl Just cause Furthermore, I hereby agree that the Clry official or a deSIgnee may enter upon the propelty to perform needed InspectIons
x
Signature
Contractor's License No.
Date
Permit Valuation 5"00. 00
Permit Fee $ ZS" _ 0 0
Plan Check Fee $ , (p, 2-5'
State Surcharge $ _50
I Penalty $
! Plumbing Permit Fee $
I
~echanical Permit Fee $
Sewer & Water Permit Fee $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
Dale
Huildlllg Ofli~ial
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; I"; $
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
TOTAL DUE $ 4-1. 75
Paid
Date
~~~4
Receipt No. ~7" k
By ~..
ThIS IS to certlty that the request III the above applicatlon and accompanYlllg documents IS III accordance WIth the City Zoning Ordinance and may proceed as requested. ThIS document
when signed by the City Planner ClmstItutcs J. tcmporalY Certificate of Zonmg compliance and allows construction to commence Before occupancy, a Certificate of Occupancy must be
i.ssued
Planning Director
Special Conditions, if any
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372