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( (t) Rio CITY OF PRIOR LAKE Date Rec'd
7 � HEATING /AIR CONDITIONING /FIREPLACE PERMIT 0, (1
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41'NNESO�� t. pink Fil .
. Green Ci PERMIT NO 4--z
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / ZONING (office use)
/ Y3,(e, && e) k'-r c r-€ B/ v
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ./ jPsr et Xt K (Phone) 952 - yl3 - 7 9 Si
(Address) /93e4 13 +r'cl, k.., 4 r f Ohl
APPLICANT
(Name) I F f �C� A% t i c ve' C 4 grrii f e El (Phone)
(Address) 7. 3 s//71/g/< t y I��'l J'70Hr'i e F/Z; 5:r_a e Z
(Adt[ress) (City) (Zip Code)
(Contact Person) "- al.' r, t, 0 ? •-,./ 6- (Phone) 763 ° 2/ 9 — Y 7 P
APPLICANT SIGNATURE V"'""� DATE 7 / f " //
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
Me�chanical ❑ Radiation
/` ` ��IA Conditioning ❑ Special Devices Fireplaces with Box Additions or
Pant cych. ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi - Family 1% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $ *re
STATE SURCHARGE $ (/
TOTAL PERMIT FEE $ 5441-
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 54 R t No/ 71W,
Date 7 /T f/
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372