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o � PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� ; TEMPORARY CERTIFICATE OF ZONING COMPLIANCE � �
� AND UTILITY CONNECTION PERMIT �U � � �
U �
'�j I. White File pERMIT NO.
� 2. Pink City � �
3 Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ?,3 1 5 W'\`� �Ov�J�-s Pq ss ZONING (oft'ice use)
(pf (� �. S53 l01.
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER ,n ' / Q 1
(Name) �6�� � t� � �J'2�SbV� (Phone) b � o�. 16 ! ' � � � S
(Address) J ` S ,� d� �C SQ G S �f U � S S� 1[�
BUII.DER - l Se�.' a-S� -' QS� �a
(Company Name) C�1 �l`'� � 1� O��� eY (af S (Phone)
(Contact Name) �� ar �ecv�n.r (Phone) '�I S�l a Q 8 S2�
(Address) � 6 coaKMe.1� � fl sS3��
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �e-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
DAddition �Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III IV V A B pROJECT COST/VALUE $_
Occupancy Group: A B E F H I M R S U
(excluding land)
Division: 1 2 3 4 5
I hereby certify that 1 have fumished information on this application which is ro the best of my knowlcdge tnie and correct. I also cenify that I am the owner or authonud agent for the
above-menhoned prope and that aU constru ' n wi onform to alI existing state and locai laws and will proceed in accordance with submittcd plans. I am aware that the buildmg
ufficial can u permit for u se F he ore, I hereby agree that t fficial or a designee may enter upon the property to perform nrcded mspections.
x �.063 S q I� Jo =�S-I I
Signature Contractor's License No. Date
Permit Valuation � Park Support Fee # $
Permit Fee •$ 7 L SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ s- Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit S
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $
This Application Becomes Your Building Pemtit When Approved Paid � l•t K ReCei t NO.
f Date B
� G�f� ( G ,'�a( � �
BuilJin � Utlicial Date
Th�s �s to certify that the request in the abuve applicanon and accumpanying documents is in accordance with the Ciry Zoning Ordinance and may proceeA as requested. This de�cument
when signed by the City Planner constuutcs a[emporary Certificare of Zoning compliancc and allows construction ro commence. Before uccupancy, a Ccruficatc uf Occupancy must be
issucd.
Planning Director Date Special Conditions, if any
24 hour noticc for al! enspections (9S2) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372