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of PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
P12/04--
0 TEMPORARY CERTIFICATE OF ZONING COMPLIANCE t� 9 /
AND UTILITY CONNECTION PERMIT "
U �
��NNBSO�P I. white File PERMIT NO.
3 Pink City � /O5/
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
x)01 ) I''' f Z
LEGAL DESCRIPTION(office use only)
LOT BLOCK/ ADDITION .„17PID o75 O -4,05-
OWNER
(Name) ,3 o, -r..., (Phone) eiS)--(197—,Sga` li
)
(Address) 51°1 1 -4-\
BUILDER
(Company Name) �.� ..e_-N-‘<s)_% (Phone) C.,) a,-.1.,. -`eo X18
(Contact Name)= e., :Xe--i•—cam .• (Phone)Ctar–gl a - L'!o`it6
(Address) c:9 114:9z) 1...,44.;... al, Cot^ecx...,,r watt, - 2,-,•-v)
TYPE OF WORK 0 New Construction ['Deck ❑Porch ❑Re-Roofing Re-Siding ❑Lower Level Finish El Fireplace
❑Addition ❑Alteration DUtility Connection
CODE: I.R.C.❑ ❑I.B.C. Misc. w''u8.*--S
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $ 4::%"- -'
(excluding land)
Division: 1 2 3 4 5
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized z.gent 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. I am aware that the building
official can revoke this permit : ausc. Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
!V 40�Mie Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ I� SAC # $
Plan Check Fee $ 4 - Water Meter Size 5/8"; 1"; $
State Surcharge $ xi,
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 $ 19. ?
This Application Becomes Your Building Permit When Approved tJlip«, it q.17 s*--- Receipt No. /�2 q- 1( 1 ate 1 q By
4.
Buildine Official Date
the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
'ity Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy,a Certificate of Occupancy must be
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