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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
DutS&/N
Date Rec' d
3. 2.3.0fj"
I While
Pink
3 Yellow
I PERMIT NO. 0& . 0 r7j
File
City
Applicant
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID Z-5': 0/7. o~ 0
OWNER
(Name)
l3o~/
(Address)
(Phone)
BUILDER
(Company Name)
(Contact Name)
(Address)
it:: f:-~ Cn~
(Phone)
(Phone)
~'
- ;( l' '2-
TYPE OF WORK 0 New Construction ODeck OPorch e-Roofing ORe-Siding OLower Level Finish 0 Fireplace
OAddition DAlteration DUtility Conne tion
CODE: DI.R.C. DI.B.c. D Misc.
Type of Construction: I II III IV V A B PROJECT COST IV ALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: I 2 3 4 5
I hereby certify that I have hlrmshed mt(llmation on this applicatIOn which is to the best of my knowledgc true and correct. I also certify that I am the owner or authorIzed agent fm the
above-mentiOned property an that all mnstruction Will conform to all eXisting statc and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
official can I' > ke thiS perm I' Just cause Furthermore, I hereby agree that the City official or a designee may enter upon the propeny to perform needed mspectlons
X 3-~M~
Signature Contractor's License No. Date
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
Penalty $
Plumbing Permit Fee $
Mechanical Permit Fee I $
Sewer & Water Permit Fee $
Gas Fireplace Permit Fee $
This Application Becomes Your Building Permit When Approved
BuiloJllg Ofticial
Date
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 $ 7(p.oo
Paid
Date
Receipt No.
By
ThiS IS to certify that the requcst In the above applicatlOn 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 Certiticate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy mllst 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