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� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
x TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT "
\; _ 27`/5--
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1. White File2PERMIT NO.
3. Pink City is- %'.._..y�
(Pleasetype orprint and sign3. Yellow Applicant
at bottom)
ADDRESSZONING(office use)
13 . 211 N,t. fvey /1)ve, /4- j it lake
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER ��
(Name) ✓1'-5Ii N / (vet rt (Phone)
(Address) /?".3.. t( g c/Tcr , 4 V . N firer c Alec
BUILDER Q
(Company Name) `O 0 Tune c (Phone) 7�2 4q7-74(1 3
(Contact Name) /MJ/zLs. �i 5•��� (Phone) 9s.- 99 y-39ia
(Address) f 0 tjk/.. A. //�r of- `-,ke
TYPE OF WORK ❑New Construction ['Deck ❑PorchRe-Roofing ORe-Siding ['Lower Level Finish ID Fireplace
IDAddition ['Alteration ❑Utility Con ction
CODE: ❑I.R.C. ❑I.B.C. 0 Misc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R SU PROJECT COST/VALUE $
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have fumished 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 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. I am aware that the building
official can revoke this ermit forcause. Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X �
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ (0/ SAC # $
Plan Check Feeg .ter Meter Size 5/8"; 1"; $
State Surcharge Pressure Reducer $
Penalty Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ 11, Builder's Deposit $
Sewer&Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DUE $
This Application Becomes Your Building Permit When Approved Paid "`'"r��i►i Receipt No.e 1'� `
Date By
Building Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This c ocument
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 S.E.,Prior Lake,Minnesota 55372