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( Z, . � Z 11 ; Yellow Applicam Please or rint and si at bottom) ADDRESS ZONING (ofcice use> ,:, �,- ? �"� l�� � .� �e. : LEGAL DESCRIPTION (oflf'ice use only) LOT BLOCK ADDITION PID OWNER r ' (Name) {� ^ ���i4•u.� Qvv (Phone) (Address) BUII,DER /� (Company Name) ���vs�. ��f--- �.�J�.J`U-iK.�.�_�L/ (Phone) �o � � °�.�� �YJ� ? (Contact Name} ,�..�.rr�. (Phone) (Address) � �j� ct,.� o .� ��-. TYPE OF WORK ❑ New Construction eck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Levei Finish ❑ Fireplace ❑Addition ❑Alteration ❑Utility Connection CODE: I.R.C. []I.B.C. ❑ Misc. ���� �r�"1 �S Type of �nstiuction: I II III IV V A B PROJECT COST/VA,LITE $ 7}� •�O Occupancy Group: A B E F Ii I M R S U Division: 1 2 3 4 5 (excluding land) i hcreby certiFy thac I have fumished information un this application which is to the besi of my knowicdge rrue and conect. f also certify that I am the uwncr or authonzcd agcnt for thc above-mennoned pr y7ty and t onstruction will conform to all existing state and local laws and will proceed in accordance with submitud plans. i am awaze that the buildmg ufficial can revo 'permit f c tse Furthermore, I hereby agree that the city o�cial or a designee may enter upon the property ro perform necded mspcctions. X ��— C�k ZC� �7_c� � Signature Contractor's License No. Date Permit Valuation �� � Park Support Fee # $ Permit Fee $ Z �r � SAC # $ Plan Check Fee $ i�p — Warer Meter Size 5/8"; 1"; $ State Surcharge $ , S o Pressure Reducer $ Penalty $ Sewer/Water Connection Fee # $ Piumbing Perrnit Fee $ Water Tower Fee # $ Mechanical Permit Fee $ Builder's Deposit $ Sewer & Water Permit Fee $ Other $ Gas Fireplace Permit Fee $ TOTAL DUE $ � ���s This piic tion ec s Your BuiCding Pemtit rn Ap oved Paid Q- . � ReCei t No. 3 � Date B , fio 26 (Z� Be DaCe Tfiis �s to certify that the r qucst n the above applicatian and accumpanymg documents is en accordance with rhe City Zoning Ordinance and may p�rocred ac requested. This document when sign � by the Ci tanne cnnstuute�t temporary Certificare of Zoning mpliane and aUows constniction tu commence. Befure uccupancy, a Cert�ficatr nf Occapancy must be issucd .� O 2�, C Z. Planning ate Special Conditions, if any 24 hour noticc for aIi inspections (9S2) 447-9850, fax (952) a47-4245 4646 Daicota Street Prior I.ake, MN 55372 � �-� , , �. i