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CITY OF PRIOR LAKE
BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
3~50
3. LEGAL DESCRIPTION
LOT
ADDITION
BLOCK
PID
(Address)
~
(Address)
1. While
2. Pink
3. Yellow
File
Cily
Applicant
Permit No.
05/a38
1. DATE
10~)~ - aS-
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(Height) (Width) (Depth)
12. NO. OF STORIES
13. TYPE OF CONSTRUCTION
(Tel. No.)
~ -J-}Qo.-7gS
(Tel. No.)
14. FLOOR AREA APPORTIONMENT USE
New Construction 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq. Ft.
(Address)
}:;k:.-.
eptic 0 Heating 0 Plumbing 0
Addition 0 Finish Attic 0 Residing 0
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
SEATS
16. ESTIMNED V. ALUE
J.f&5S.0D
17. COMPLETION DATE
9. PROPERTY DIMENSIONS
Width Depth
10. CULVERT SIZE
Yes No
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
at all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the
. for just cause. Fu ermore, I hereby agree that the city pllicial or a designee may enter upon the property to pe orm needed inspections.
UJ 5tp (9 0- ) d - U!::>-
Ueense No. Date
x
SETBACKS: Required
Actual
FOR ADMINISTRATIVE USE
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
SewerTap ................................... $
License Check Fee ......................... $
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
o Sewer & Water Connection Fee ........... $
o Water Tower Fee ........................... $
Water Tap ................................... $
Builder's Deposit ............................ $
Other ......................................... $
Total Due .............................. $
Paid . , (J
Date /0. /1. OS B
This is to certify that the request in the above application and accompanying documents is in accordance w~h the C~ Zoning Ordinance and may proce
signed By the C~ Planner const~utes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certific
Front
Back
Side
PROPOSED GRADE FOUNDATION
IN RELATION TO CURB OR CROWN
OF STREET
USE OF BUILDING
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
~H//L
,
TYPE OF CONSTRUCTION: I II III IV V
City:
Occupancy Group A BEl H R M
Division 1 2 3 4
Permit Fee ................................... $
Plan Checking Fee ......................... $
State Surcharge ............................. $
Penalty ....................................... $
Septic System............................... $
Other ......................................... $
Check if
Deferred
Subtotal............................... $
This Aplication Becomes Your Building Permit When Approved.
By
Date
Certificate of Occupancy
Issued
City Planner
Date
24 Hour notice for all inspections 447-4230 9:00 a.m. . 10:00 a.m.
Special Conditions ~ any
Side
MATERIAL FILED WITH APPLICATION
SOIL TESTS 0 ENERGY DATA 0
'21 .s-()O. IJ ()
PILING LOGS 0
PLANS & SPECS 0
SURVEY 0
PLOT PLAN 0
PERCOLATION TESTS 0
SETS
COPIES