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, ., � CITY OF PRIOR LAKE
'� � 16200 Eagle Creek Av. S.E. permit No. �5 �� Single Family �_ Two-Family Multi-Family
��� � Prior Lake, MN 55372
� :� � `� Commercial Industrial Public Other
` HEA�`ING APPLICATION / PERMIT �pg VALUATION FEE
Date R PID # 2-S - �,�5' �2 �-a
$0 -$1,000 2% of job value, min. $20.00
Site Address �Z Z � t/ � G.
Lot � Blodc � Addition ' $1,001 -$10,000 $20.00 for the first $1,000 plus $1.25 for each additional
$100.00 or fraction thereof to and including $10,000.
Owne�'s Name ���Gl� SD/�ES
$10,001 -$50,000 $132.50 for the first $10,000 plus $1.00 for each addi-
Address S Z Z- 9 e�}�� y �d✓F T/�'/� L tional $100.00 or fraction thereof, to and including
Heating Contractor /�l�sh' �l�y $"�o A�►'� �o�d � ��N %^'y �so,000.
Address �OZ y� L- /�i��R.J� �IV� J /� ° aROo�l.'/ ,� �l�i� $�0,001 and over $532.50 for the first $50,000 plus $7.50 for each addi-
`��� tional $1,000 or fraction thereof.
Telephone # S 3(P - o!� �7
yJ �,, The price of your heating permit includes one rough-in and one final inspection.
Furnace Make & Modet � F��oX GZ3 TYPE OF SYSTEM Additiona! inspections will be billed at $25.00 each.
Warm Air P�ants
Model Size 1a� ► �� � �� Gravity House Heating Test Record musi be submitted with bui�ding�permit number before build-
Conn. Load SV� 4�� �JP^ ll�C� Mechanical LP���C GZ3° �y -/� ing certific%' -` -
Air Conditioning L c��+�►�I l�SZlo ^ 5���
Fue) N�. Flue Size ��� Vent. System � CLOSED DUE TD ply and return openings listed
HEATING OR POWER PLANT Per room H �ACTIVITY 8/30/01 ��ans send floor plan with sup-
Supply Openings ply and re JLATIONS, PAYMENT AND
Steam
Return Openings Hot Water APPLICATI __ _.. ...� rRIOR LAKE, 4629 Dakota St.
Radiation S.E. Prior Lake, MN. 55372.
Input JOVi v v a Output _ g �� o� a Special Devices
City Hal( business hours are 8 a.m. - 4:30 p.m.
Edr.
Cfm.
1 � v � Other Devices ALL WORK MUST BE INSPECTED (ROUGH-IN AND FINAL) - CALL CITY HALL
447-4230.
TYPE OP WORK I hereby apply for mechanical systems permit and I acknowledge that the information
Alterations Replacement �^ New Construction above is complete and accurate; that ti�e work will be in conformance with the ordi-
nances and codes of the city and wiih the state building/mechanical codes; ihai this form
Repair Est. Comp. Date does not become a permft until signed by the BUILDING OFFICIAL; that the work will be
Est. Cost $ 35 �� in accordance with the approved plan in the case of all work which requires review and
Building Permit # approval of la
HEATING PERMIT FEE $ ��� Z S �/� ��'�� O��' �S
STATE SURCHARGE $ .50 IicanYs Signature Date
� TOTAL PERMIT FEES $ � �• 7 � Receipt # oL� 7� a � � �—��
Buildi Official's Signature Date
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