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of PRio� CITY OF PRIOR LAKE BUILDING PERMIT, Date Reo'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ✓ < � ��
.. AND UTILITY CONNECTION PERMIT
U t r j
i
'tI A,NeS� ` z. Pink City �' I. White File
' PERMIT NO. / 2 16,
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / —� ZONING (office use)
"' t, O C.�s lJ�
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER i �� Ct C /� q) n 51 _ c� 1 g
(Name) �`� �. - \� \. U�A-- (Phone) J pt-'° Dv [ J 1
(Address)
BUILDER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK ❑ New Construction Deck EPorch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish r] Fireplace eve W/
❑Addition ❑Alterat EUtility Connection �1 , f
CODE: ❑LR.C. ❑LB.C. ❑ Misc. , /L/4/9 O /Y i � Les
Type of Construction: I II III IV V AB / SPA ij d
Occupancy Group: A B E / H I M R S U PROJECT COST /VALUE $
(excluding land)
Division: 2 3 4 5
ti
I hereby certify that I have furnished informatio m this application which is to the best of my knowledge true and correct. I also certify that 1 am the owner or authorized agent for the
above -' enoned prope and that all constru i n will conform o all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
otTicial n revoke this mit for just cause. F n ermore, I he agre hat the city official or a designee may enter upon the property to perform nee •d mspec aware
—1 — /:
X
Signature r Contractor's License No. Date
t,,_ 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 $ 41:1S
This Application Becomes Your Building Permit When Approved Paid ... - Re ipt / ` A1•
Date 3 ( ?—/ '- ii
Building Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street Prior Lake, MN 55372