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oF pRlp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLTANCE
� � AND UTILITY CONNECTION PERMIT ,_,�/_��
U (
'Irj�, �. Wh,�e File pERMIT NO.
2. Pink Ciry �'�
; Yellow Applicant
Please e or rint and si at bottom)
ADDRESS ZOIVING (ofTice use)
3 U G � rC� ti--� � („�� r. �Q : V y� L�:. k..�. � y ty� Z.
LEGAL DESCRIPTION (of�'ice use only)
LOT BLOCK ADDITION PID
OWNER /
(Name) —���.,. 1 V�?c�1 t Z„ (Phone) Gl �+ � � � O ��
(Address) ��- �..�
BUII.DER `` �T ��1Z�'$��," `�tjc�
(Company Name) r � � rnAr'� (Phone)
(Contact Name) �H�K �+ s..0 .,.. (Phone) �n (Z ^ 7 �a - ���(")____
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch '�e•Roofing ❑Re-Siding ❑Lower Level Finish ❑ Fireplace
�Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Consmiction: I II III IV V A B pROJECT COST/VALUE $ Q. ° L�
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
I hereby certity that I have (i�mished information on this application which is w the best uf my knowlcdge true and correct. 1 alsu certify that I am the owncr or authorizcd agcnt for the
above•menttoned property and that all cunstruction will conform ro all existing state and local taws and will proceed in aaordance with submitted plans. I am aware that the buildmg
official can revoke thi permit f cause Furthermore, I hereby agree that the city official or a designee may enter upon the propecty m perform needed tnspections.
X - -a � �� ' �' 2
Signature Connactor's License No. Date
Permit Valuation � Park Support Fee # $
Permit Fee $ ��-� �S' SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ d(j 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 DLTE $ '� _
This Application Becomes Your Building Pemui When Approved Paid �- �G ReCei t No.
Date — i B
��e_ �—�-I —12
Buildine Utticiat Date
Th�s is to certify that the request in the above applicat�on and accompanying documencs is in accordance with the City Zoning Ordinantt and may prixeeA as requcsted. This document
when signed by the City P(anner cansututes a remporary Certificate of Zoning compliance and allows construction tu commence. Befure uccupancy, a Cernticate uf Occupancy must be
issucd
Planning Director Date Speciat Conditions, if any
24 hour noticc for all inspections (9S2) 447-9550, fax (9S2) 447-4245
4646 Dakota Street Prior Lake, MN 55372