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4 P 1110 CITY OF PRIOR LAKE Date Reed
A ,, HEATING /AIR CONDITIONING/FIREPLACE PERMIT t 1 3Q ,
� 1. Pink Fik NO.
`'tlNivESa � z, crcen F • PERMIT NO ( i f 2_7.6
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
cc O . 6/0 lr y Cy i'r c,16
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER // n
(Name) , C / r is 4' in )� k &i A w r e N 10 & (Phone) 9 s ' .11; -; C
(Address) .5 /O ' G I , - y e i'r01 e- , P i s, ' I r �G✓k: e -, 41- 5C 3 `t-
APPLICANT y� y
n o� r
(Name) .Sb�[,q/'S /d e, a/t L.. -i J (Phone) "l S 'D y ° S
(Address) /t c if e b - Al n r i' a- Iv ela ' le__ 8 1 UL,- 6 /1)Vent P MA, 1 Y1 n 55
p j (Address) L (City) (Zip Code)
(Contact Person) � t t D " -r t. � i-e-4:'�r p 7� / (Phone) g5 e "' ' 4' y-r3
APPLICANT SIGNATURE A I ..d .4: 1. l DATE 1/ 2'5 ' //
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL l- h J e h - _ �g t/1 D FUEL (V
FLUE SIZE 4V-S" RETURN OPENINGS INPUT SIOMi OUTPUT Z /14
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.
El Mechanical ❑ Radiation Fireplaces with Box Additions or
['Air Conditioning ❑ Special Devices
[Went. 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
/rU
Estimated Cost $ .21.5'1 Building Permit #
HEATING PERMIT FEE $ 4 /9. ST)
STATE SURCHARGE $ 6 - 2 3
TOTAL PERMIT FEE $ S `/. S
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Sv Rr No. t ch /
Date
Buildlne Official Date / 2- ' Z l
24 hour notice for all inspections (952) 447 - 9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372