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CITY OF PRIOR LAKE
REA TINr . . ~~ ,-,r......T-n.........r1>l\o.TT1\,Jr' IVTDlf,PLACE PERMIT
THIS FILE HAS BEEN
CLOSED DUE TO
INACTIVITY 4/16/2008
Date Rec'd
Pink
Green
Yellow
~~:y I PERMIT NO. (J' '7 - 77 4
Applicant -:; (
. .ease type or print and sign at bottom)
ADDRESS
ZONING (office use)
/5;)~
LEGAL DESCRIPTION (office use only)
LOT BLOCK ~ ADDITION
~.
PID
~ 3&:;1- D5/
OWNER
(Name)
/ltitf/./ /J
~~V/
(Phone) q?;7>-o:EJ({J -/::JV
(Address)
/1/
APPLICANT /'l .
(Name) (/A~~dY C~~y Ad~JO')
(Address) )X~/? VLJ"/~/ I7V A/;!
(Address)
(Contact Person) ~'S/J?'/
APPLICANT SIGNATURE
(Phone) ;03- 7~'7-/L:JCJa)
,
A.-Jd&i ~ 553:t:f
(City) (Zip COde)
(Phone) .6v.,)-~ /-;5,096
DATE 7t-dgf23
APPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION 0 REPLACEMENT 0 AL TERA TIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM
OWarm Air Plants
OGravity
o Mechanical
OAir Conditioning
OVent. System
HEATING OR POWER PLANT
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
Residential, Heating & AIC (New Construction)
Residential. Heating Only (New Construction)
FEE SCHEDULE
I % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential. Additions & Alterations
$64.50 Residential, AC Only
$39.50
Industrial, Commercial & Multi-Family
$39.50
$39.50
[roI-///Vd. a~
tv / /(;J// 67A
t;l%/f' "..
Estimated Cost $
/53. c6
.
Building Permit #
HEATING PERMIT FEE
ST ATE SURCHARGE
TOTAL PERMIT FEE
$ L;t/"
$ .50
$ '7'"17.. &D
'''ffice llse Only)
'his Application Becomes Your Building Permit When Approved
Date
Paid ..tQ L{ 0.' /
Date 3
~,~
Receipt No. ..'"
( t5q ;;
By
Building Official
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245