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oF PR1p� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
.�'. X AND UTILITY CONNECTION PERMIT
v �,
'�jA,NESO�e' I. Whi�e File pERMIT NO. -�1 �'
2. PinA CitY ' � ^.
3 Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ZOIVING coti',cc use)
iJ � � �''
� � ,�,;� � , - �
LEGAL DESCRIPTION (oflfice use only)
LOT BLOCK ADDITION PID
OWNER p
(Name) 1 � i n ���� � � �,� e� ✓1 (Phone) QSv�--y� � l G� S
(Address) p , V,/��W � - < �
BUII.,DER
(CompanyName) nC`�,�Y� �X���i`plS (Phone) �7��
(Contact Name) �.YYI� �'��.� (Phone) �S`/ 3r7 — y�/��_
(Address) �Vc.� o_ >
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch �Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Constiuction: I II III IV V A B pROJECT COST/VALLTE �_ E� � Od
Occupancy Group: A B E F H I M R S U (excluding land) —T
Division: 1 2 3 4 5
1 hereby certify that I have (i�mished mformation on this application which is to the best of my knuwlcdge tnie and correct. I also certify that I am the owner or authorized agent for the
alwvamenuoned properry and that all construction will conform ro ali existing state and local laws and will proceed in accordance with submittcd pians. I am aware that thc buiidmg
official can revuke this permit for ju t cause Furthermore, I hereby agree that the city official or a designee may enter upon the property ro perform necded inspecuuns. '
.�--.- �� ��syy�
Signature Contractor's License No. ate
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 # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $
This Application Becomes Your Building Permit When Approved Paid ReCCi t No.
� Date B
_ Go�.�"' � - I �-
Buildina Utlicial � Date
Th�s �s to certify that the requcst in the above applicanon and accumpanyin� documents is in accordance with the Ciry Zuning Ordinantt and may proceeA as requcstcd. Th1s document
when signed by the Ciry Planner consumtes a rempurary Certificate uf Zoning compliance and allows construction to commence. Before uccupancy, a CeruFicuc uf 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