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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
n at bottom)
ADDRESS
Date Rec' d
10, 2-7,,~S-
White
Pink
Yellow
I PERMITNOoa5_lo11I
File
City
Applicant
ZONING (office use)
3(, 2-5 W/~l.--OW #dferl S'/:
K..-I S ~
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID zG". I d t. 6 L-I. ()
OWNER
(Name)
(Phone)
(Address)
BUILDER
(Company Name)
(Contact Name)
(Address)
Hrr<;<r
(Y1 J ce
[.d
A(X)h i7y -"Jit G .
d-oO~ Si
1))'~1~-!Jyr;A
mtJ
TYPE OF WORK 0 New Construction ODeck OPorch ORe-Roofing ORe-Siding OLower Level Finish 0 Fireplace
OAdditlon OAlteration OUtility Connection
CODE: OLR.C. OLB.C. o Misc.
Type of Construction: I II III IV V A B PROJECT COST IV ALUE $
Occupancy Group: A B E F H I M R S U (excluding land)
Division: I 2 3 4 5
x
I hcreby ccrtlly that I have furnIShed mformation on this application which is to the best of my knowledge true and correct. I also certIfy that I am the owner or authorIzed agent for the
.1bovc-mentlOned pro erly and that all constrUCl1on will conform to all existmg state and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
offIcial can revok 'I S permit I'm Just cause Furthermor I hereby agree that the Clly official or a desrgnee may enter upon the property to perform needed mspec OIlS
/0 a7 CD
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
I
i Penalty $
i Plumbing Permit Fee $
~"h"'i"] P"mil Pee $
Sewer & Water Permit Fee I $
r Gas Fireplace Permit Fee $
I This Application Becomes Your Building Permit When Approved
!
I
i
L-
1311i1dll1~ U11Icial
Date
Contractor's License No.
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; I"; $
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
..... ~
TOTAL DUE $ 'l~. ,tJ
, /
Paid ~...-
Date '0..) 7 {; f
I~NO
5034,/
I"I11S IS to certIfy thaI thc requcst m the aoove applIcation and accompanymg 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 uf Zonmg compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued
Planning Director
Special Conditions, if any
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372