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CITY OF PRIOR LAKE
HEA TIN({t1 Aln. ':ONDITIONINGIFIREPLACE PERMIT
(Address)
(Contact Person) ~N ~/C/6LL-A
APPLICANT SIGNATURE !}::;:r}~ ~~
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APPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION 0 REPLACEMENT 0 AL TERA TIONS
FURNACE MAKE AND MODEL FUEL
(Please type or print and sign at bottom)
ADDRESS
1. Pink File
2, Green City
3, Yellow Applicant
/53/ / 8eEE:ZY PO/NT !2.fJItD
LEGAL DESCRIPTION (office use only)
LOT/4--~(<fK
Bee-EZY ~ I .
ADDITION
OWNER
(Name)
RIXMANN
. (Phone)
(Address)
APPLICANT
(Name)
(Phone)
(Address)
(City)
(Phone)
DATE
FLUE SIZE
RETURN OPENINGS
TYPE OF SYSTEM
OWarm Air Plants
o Gravity
o Mechanical
OAir Conditioning
DVent. System
(~PLA~KEANDMODEL _
~ -
INPUT
REA TING OR POWER PLANT
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
Industrial, Commercial & Multi-Family
FEE SCHEDULE
I % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
Residential, Heating & AlC (New Construction)
Residential, Heating Only (New Construction)
Estimated Cost $
Building Permit #
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$~~ 50
$' .50
$ 1-0. 00
(Office Use Only)
Paid lfo. oU
Da'l_ d-3-Q I
4'23-01
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
Date Rec'd
4-2.'3-0 I
03l15".
PERMIT ~~!JI- 0 3q~
ZONING (office use)
R/5D
PID 25 -OZfe,- I?o!j-O
(Zip Code)
OUTPUT
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
$39.50
$39.50
$39.50
Receipt N<rr S{
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