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OF PRI CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
411PIVESOit' I White File
2 Pink City PERMIT NO . / ' / _ ,L 9 7
T 3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
�L G ; 7 6 J " J
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) G - , ; i- (Phone)
(Address)
BUILDER 1 ,-
(Company Name) 1Z13Q'.+UC X G'f 4 G'Y (Phone) 74,:i 3 - S, . /d '8
(Contact Name) ,) 1` .j6 _ (Phone) t ` t
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ARe- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑LR.C. ❑LB.C. ❑ Misc.
Type of Construction: I II III IV V A B
PROJECT COST /VALUE $ 1
Occupancy Group: A B E F HI MR S U (excluding land)
Division: 1 2 3 4 5
1 heteby certify that I have furnished information on this application which is to the best of my knowledge true and con ect I also certify that I am the owner or authorized agent for the
above - mentioned . . - and that a nuction will conform to all existing state and local laws and will proceed in accoidance with submitted plans I am aware that the building
official can revoke this per • ust cause t more, I hereby agree that the city official or a designee
� n__ee may enter upon the pioperty to perform needed inspections
X — ✓ b1r W4J (05 `�6 _ ( Cf
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 $
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 $ 79' 75
This Application Becomes Your Building Permit When Approved Paid 'I . /5 Recei t o. 7/ / C7
Date ,,57/ b y-- By( y�i
i
Building Official Date
This is to certify that the request in the above application and accompanying documents is in accoidance with the City Zoning Ordinance and may proceed as iequcsted 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