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- _ PRio CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
n AND UTILITY CONNECTION PERMIT - et , 1 4-
yi'si.E.„ i White File P ERMIT NO. I �, ] L�
Pink A 1 �.1�r J
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
i 5.—a vv ) A
H o6L fo.3J (v47- (tti
LEGAL DESCRIPTION (office use only) �'
LOT BLOCK ADDITION PID c 382 — DI - 0
O a WNER S fi lA �il. � r o Y1 � (Phone) CS- — y'Yo - 6 Od 7
(Address)
i BUILDER
(Company Name) ( C o G A/ (Phone) 6 (,>) ?° T _ �y�
' c?` 'i'
(Contact Name) �7 `) / 0 n V /�, (Phon j 1 e/ M
(Address) t 3J / ''� I V 0 E? &^ 1/ � / e ,,y -S34'7
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch . e-Roofing 0Re-Siding ['Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc
Type of Construction: I II III IV V AB PROJECT COST /VALUE $ g r v 0 0
Occupancy Group: A B E F HI MR S U (excluding land)
Division: 1 2 3 4 5
1 hereby certity that I have banished mtbrmation on this application which 0 to the best of my knowledge true and correct I also ceinfy that 1 am the owner of authorized agent for the
above - mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans l am aware that the building
official can revoke this pet met for lust cause Fuithermore, 1 hereb gree that the city official or a designee may enter upon the property to perform needed inspections
Signature Contractor's License No Date
Permit Valuation Park Support Fee # $
Permit Fee $ r7L/ 17 5 SAC # $
i
Plan Check Fee $ Water Meter Size 5/8 ", I"; $
State Surcharge $ 5 1117 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 1 $ TOTAL DUE $ 17 £ ) f7
This Application Becomes Your Building Permit When Approved Paid u /5 — Receipt No. - / i d- L Q
Date G , 7 • 1 LE By 6w4(,,t1
Building Official Date
This is to certify that the iequcst 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 Ceinficate 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