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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
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White
Pink
Yellow
I PERMIT NO. C)tv ()3711
File
City
Applicant
PQ.iO~.~'
ZONING (office use)
,5~7~
mil
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
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OWNER (;, e ()c- *-
(Name)
(Address) \~<{bO
i~e'S . (Phone)
~ ~W - ?a..lal L(l~,
qs~ - d d~?-3iS-'
1111)9.;-:) -7 '~
BUILDER
(Company Name)
(Contact Name)
(Address)
(Phone)
(Phone)
TYPE OF WORK 0 New Construction ODeck OPorch Re-Roofing ORe-Siding OLower Level Finish 0 Fireplace
OAddition OAlteration OUtility ConnectIOn
CODE: DI.R.C. DI.B.C.
Type of Construction:
Occupancy Group: A B
Division:
III
H
2
V
M
4
A
R
5
IV
I
3
I
E
II
F
I
o Mise.
B
S
U
PROJECT COST IV ALUE
(excluding land)
$
I hereby certit)' that I have hlfnlshed 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 thc
abovc- 'ntIoned property and that all Cllnstruction wIll conform to all eXIsting state and local laws and will proceed in accordance with submItted plans, I am aware that the building
:frCl' c revoke tlus per:'11~ls~ Fu 'thermore, I hereby agree that the CIty official or a designee may enter upon the property to perform neeSn.'Pjctss _ [J C:::,
Sig Contractor's License No, Date
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
Penalty $
Plumbing Permit Fee $
Mechanical Permit Fee $
Sewer & Water Permit Fee $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
Buildl1l!! Umcial
Date
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; 1"; $
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
TOTAL DUE $
ThiS IS to certify that the request in the above applicatIon and accompanymg documents is in accordance with the City Zoning Ordinance and may proceed as requested ThIS document
when signed by the Crty Planner const!tlltes a temporary Certificate of Zonrng complrance and allows constructIon to commence, Before occupancy, a Certificate of Occupancy must be
issued
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