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DATE RECEIVED 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
BEI'O PERtvllT I~.ISSUED (Please Print or Type and sign at bottom)
L White
2. Pink
3. Yellow
(Depth)
12. NO. OF STORIES
LOT
ADDITION
.:2 PID QS- 23 Cf-o()6 -0
~rvzl~}
13. TYPE OF CONSTRUCTION
BLOCK
~iru:Jh l-h J I
dName)
"'b~~(~
(Name)
~. O~ ;;;L
(Address)
(Name)
(Address)
Sc<- v1A.. <..
Ci.b OWV4-€~
14. FLOOR AREA APPORTIONMENT USE
(Tel. No.)
(Tel. No.)
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS
SEATS
16. PROJECT COSTNALUE
eJJ-
17. COMPLETION DATE
Fireplace 0
Alteration~
Septic 0
Addition 0
Deck 0
Finish Attic 0
Re-roofing 0 Porch 0
Re-siding 0 Finish Basement 0
"
-...' ""
New Construction 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq.Ft.
9. PROPERTY DIMENSIONS
Width Depth
10. CULVERT SIZE
Yes No
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
truction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I m aw e that the
cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform ne ed i actions.
tJt?
License No.
SETBACKS: Required
Actual
FOR ADMINISTRATIVE USE
MATERIAL FILED WITH APPLICATION
Amount Brought Forward .................. $
Park Support Fee ........................... $
SAC ......................................... $
Collective Street Fee ....................... $
Sewer Tap ................................... $
$
Pressure Reducer .......................... $
Meter Horn ................................... $
Water Meter ................................. $
Sewer & Water Connection Fee ........... $
Water Tower Fee ........................... $
Water Tap ............. ...................... $
Builder's Deposit ............................ $
Other ......................................... $
Total Due .............................. $
Paid ~ S- Receipt
Date 5. '3' (f1/ By
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed s requested. This document when
signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued.
Front
Back
Side
BUILDING DEPARTMENT VALUATION
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION
S'oo .00
USE OF BUILDING
TYPE OF CONSTRUCTION: I II III IV V
Occupancy Group A B E F HIM R S U
City:
Division 1 2 3 4
2'1.0
I 3. (Pt;;""
.~c)
Permit Fee ................................... $
Plan Check Fee ............................. $
State Surcharge............................. $
Penalty ....................................... $
Plumbing Permit Fee ....................... $
Mechanical Permit Fee ..................... $
Sewer & Water Permit ...................... $
.......... $
3.00
~.
This
By
Ullding Permit """~tE!'Qye~. _ ,
Date e1 ~
Certificate of Occupancy
Issued
City Planner
Date
24 hour notice for all inspections (952) 447-9850
Special Conditions n any
Side
SOIL TESTS
o ENERGY DATA
o
PILING LOGS 0 PERCOLATION TESTS 0
PLANS & SPECS 0 SETS
SURVEY
PLOT PLAN
o COPIES
o
"'..,
PRIOR LAKE
INSPECTION
RECORD
DEPARTMENT OF
BUILDING AND INSPECTION
SITE ADDRESS ~ J../U\M.~I~\)--f'Q
TYPE OF WORK J::v.sk...ll \J.h"P~<} O"\.^. ,&""t'a Sc Nut.M- ~nJ......
USE OF BUILDING S'f?O
PERMIT NO. 00 . 0 ~ 78 DATE ISSUED 8 - )-'2.0cq
BUILDER -U~~ LJo3 -t:j S-IS-
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR
DATE
1-llL- .1&n I I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
I ~ ~ ~/ed~~vku ., I I
I FINAL I I
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS 447-9850
"
. .