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(jRi CITY OF PRIOR LAKE Date Rec'd
e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
x
1-1NNESD�� 1. Pink File PERMIT NO
2. Green City ii, /„
3. Yellow Applicant r�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 l4 bluebird MU QE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) tkk) 1ne 1914.5 (Phone) 53' a33 -acalLl
(Address) KOM B\uebtrd Trail N E
APPLICANT (I , I, f '�( 5 (Name) KOnS ����
�� I (Phone) "I _ `'i
(Address) ISOi0 Q1d brick. Oat PLO ankapee 55399
„(Address) (City) (Zip Code)
(Contact Person) 0 ' (Phone)
APPLICANT SIGNATURE SO: i , Y `�" DATE (0
4
APPLICA PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION E'�tEPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL Pei l.JO" riev ' - h3li 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.
❑36echanical ❑ Radiation
irrAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
EVent. System ❑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 $ .�
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 61- 5 ) jNo. 6,L 763
Date / Q t( Buildin¢ Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372