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oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
� x AND UTILITY CONNECTION PERMIT
� �
'�'j I. White Fife pERMIT NO. lZ _��� �
2. Pink City �
3 Yellow Applicant
Please or rint and si at bottom)
ADDRESS ZONING (ott'ice use)
�fq�5 �O �� s �,
LEGAL DESCRIPTION (of�'ice use only)
LOT BLOCK ADDITION PID
(Na�m E � �� � �� G�/�/ (Phone) ��� ���(D "���
(Address) ^ O �
BUII.DER �'"- �� � I��'J�� p/ D'J'!� � � /✓ � ` �/Q"" J f
(Company Name) U Y� S+ G���N� (Phone)'
(Contact Name) .�b �"" � �i�� � �` , (Phone) ��'�U ✓��3�
(Address) � , L /� / � � K G.,"' �/ �/ � j `�J�J ��,
TYPE OF W�RK ❑ New Construction ❑Deck ❑Porch Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteradon ❑Utility Con ction
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Conshuction: I II III N V A B pROJECT COST/VALUE $, �D �^
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certify that I have fumished information on this application which is to the best of my knowlcdge true and correct. 1 also certify that ! am the uwncr or authonzed agent for the
above-mennoned property and that all consa•uction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
official can revoke this permit for just cause. Furthermore, I hereby agree that the ciry official or a designee may enter upon the property to perform needed mspections.
X
Signature Contractor's License No. 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 # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $ �i "'
This Application Becomes Your Building Permit When Approved Paid Recei t O.
Date B
BuilJin � Ut7icial Date
This is ro certify that the requcst in the above applicanon and accompanying documents is in accordance with thc Ciry Zoning Ordinantt and may pnxeeA as requcsted. 1'h�s dixument
when signed by the City Planner consumtrs a temporary Certificate of Zonmg compliance and allows construction to commence. Before occupancy, a Ceruficate uf Occupancy must be
issued.
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447-9RS0, f�x (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372