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CITY OF PRIOR LA
TEMPORARY J LAKE BUILDING PERMIT,
ERTIFICATE OF ZONING
AND UTILITY CON NECTION pERMIT
COMPLIANCE Date Rec 'd
+ `Nlveso'tt•
Please , or , tint and si
at bottom I. White File
ADDRESS hink Cit
3 YYellow Appiitant PERMIT NO. i i
' /
0 s`v S
LEGAL zr G (office use)
s_o DESCRIPTION (office use only)
LOT BLOCK ADDITION
OWNER
(Name) � � PID
(Address)
B _ (Phone) -7 ‘ ' LC 4
•
BUILDER
(Company Name) AP ' _ - s
(Contact Name)^
d
' — (Phone
(Address) )
�, y (Phone) _.zs.� -- _
TYPE OF WORK .. ��
❑ New Construction
Addition °Deck ❑Porch �
DAlteration ❑Utility Connections Roofin g ❑Lower Level Finish ❑ Fireplace
g �Re -Siding
CODE: QLR.C• QLB.C.
TYPe of C onstruction: I II III TV V A B
Occupancy Group: A B E F
I 2 I MR SIT PROJECT COST /VALUE
I hereby 3 4 5 • 1
Y certify that I have furnished information on this a (excluding land) $ — — _� C yC
------- _______
I he can revo st d that all construction will conform f orm to all existing
1 ! this per mkt for hick is to the best of my knowfed e
°11 / cause Furth g hue and correct. I also e
X g state a local laws and e wia proceed in accordance with e submitted rneede plans. I am <
I hereby agree that the city official or a rh that I am the owner or authorized agent for the
abo ve - mentioned �
designee may enter upon the property to perform needed inspect- ms. ignature gr ' , N
aware tha the building
Contractor's Licens- No.
Permit Valuation Park Support Fee
Permit Fee bate
Plan Check Fee #
Water _.
Penalty
7 11.111.1111111111 .11 11111111 11111111, C)
Pressure Reducer
Meter Size 5/8'°
Plumbing Permit Fee ■■ Sewer/Water Connection Fee # .
Mechanical Permit Fee
Water Tower Fee
Sewer & Water Permit Fee # • -
$ Builder's Deposit
miminum aIMIIIIIIIIIIII
Gas Fireplace Permit Fee
Other
T TOTAL DUE
gligibiall
. t)ffi
■ P Becomes Your Building Permit When
n Approved �-
- Paid 141. etu ldin, fret : Date :rsnnr...__(VUIIIIIII Recei.t No. ` O cial B
D< t An7 Al--
This is to certify that the request in the above a
temporary
application and accompanying documents is in
poraty Certificate of Zoning compliance and allows construct ion the to
accordance
City Zoning Ordinance and may proceed as requested. This document
when signed by the City planner constitutes a
commence. Before occupancy, a Qrtificate of Occupancy must be
Planning Director
24 hour notice for Date
Special Conditions, if any
all inspections (952) 4 47 -9850 fax (952) 447_4245
4646 Dakota Street Prior Lake, MN 55372