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White File � ��, � �� 2. Pink City PERMIT NO . 3 Yellow Appliwm / �•�� Please or rint and si at bottam ADDRESS ) ` � � ZONING (o�'ice use) /�_ Uz� � / LEGAL DESCRIPTION (ofl�ice use onty) LOT BLOCK ADDITION PID OWNER (Name) cO (Phone) (Address) BLTII,DER � �� s � � � (Company Name) �� �� lZt I ll 1` OCt ta ?' T� (Phone) rP � (Contact Name) (Phone) '�'1 Z 3 �? 3. &� (Address) ,,`a �u ��E' ��—` TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re•Roofi ❑Re-Siding ❑Lower Levei Finish ❑ Firepiace �Addivon �Alteration ❑Utility Connection / ��� ( CODE: ❑I.R.C. ❑I.B.C. iJ '�- Type of Constiuction: I II III IV V A B PROTECT COST ALLTE S �J19�[� � B� Occupancy Group: A B E F H I M R S U (excluding land) Division: 1 2 3 4 5 ! hcreby certify that I have fumished information on this application which is ta the best of my knowledge mue and correct. 1 atso cercify that 1 am the owncr or authimzed agent For the above-mennoned pro that all construction wip conform to ail existing state and local iaws and will proceed in accordance with submitted pians. I am aware that the buitdmg ufficial can revoke th mit for ca rthexmore. I hereby agree that the city official or a designee may enter upon the properry to perform necdcd i�ms. � X /�S 20/ 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 $ Penaity $ Sewer/Water Connection Fee # $ Plumbing Fermit Fee $ Water Tower Fee # $ Mechanical Permit Fee $ Bui(der's Deposit $ Sewer & Water Permit Fee $ Other $ Gas Fireplace Permit Fee $ TOTAL DUE $ This Appiication Bernmes Your Buiidittg Pertnit When Approved Paid � R ei t NO. Date U , � , L Buildin � Utiicial Date This �s to certify that the requcsi in the atwve apptication and accumpanying documents is in accordance with the City Zcming Ordinance and may proceed u requcstcd. This document whert signed by the City Planner cunshtutrs a temporary Certificate of Zoning compiiance and alli�ws conswctinn to commence. Before �xcupancy, a Cernficate ��f Occupancy must be icsucd- Planning Director Date Special Conditions, if any 24 hour noticc for all inspections (9S2) 447-9850, fax (952} 447-4245 4646 Dakota Sireet Prior Lake, MN 55372