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oF rRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� X AND UTILITY CONNECTION PERMIT �� -� � ��"
�
���'NESO�� I. Whi�e File r ��
z �;�, � PERMIT NO. ,
3 Yellow Applicam
Please or rint and si at bottom)
ADDRESS ZOIVING (ott'ice use)
� c� 7 l,c,c� �ve�IC � d' .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER y �-
(Name) �� wl t l �S�`Q � (Phone)
(Address) � (,c�QC� �/C�C, C (/� .
BUII.DER �n n /' �
(Company Name) T���'� IL°L-S tC�/�'�`� Cr.�t C�r/'c1 ✓ ID (Phone) 7� 3 ?d -aa 7�
(Contact Name) c ` �i � (Phone)
(Address) f e /" ��/`�
TYPE OF WORK ❑ New Construction �Deck ❑Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utiliry Connecnon
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc. `� �' �`t� ` �� `�
Type of Construction: I II III N V A B pROJECT COST/V UE $ Q� ��
Occupancy Group: A B E F H I M R S U (excluding land) f
Division: 1 2 3 4 5
1 hereby certify that I have (iimished information on this application which is to the best uf my knowlcdge tnie and correct. I also certify that ! am the uwncr or author�zcd agent for thc
above-menuoned prope and that all construction wi11 conform to all existing stare and local laws and will proceed in accordance with submitted plans. I am awarc that the buildmg
official can revoke th rmit for just c e F ermo , I reby agree that the city official or a designee may enter upon the property to perform necded mspe iuns.
X y.� � 6,3 7z3 � S Zz �Z
Signature Contractor's License Na Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Piumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DLJE $ �
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This Application Becomes Your Building Permit When Approved Paid ei t NO.
Date t
Buildins Utticial Date
Th�s �s to certify that thc requcst in the above appticat�on and accumpanying docUments is in accordance wich chc Ciry Z��ning Ordinance and may proceed as requcsced. This dixument
when signed by the City Pianner consnrotes a tem{wrary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Ceruficuc of Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for all inspections (952) 447-9850, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372