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° ' CITY OF PRIOR LAKE Date Rec'd
I HEATING /AIR CONDITIONING/FIREPLACE PERMIT
A'NESO
1. P G reen F / e PERMIT NO. ` , / / 9�
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS sr s
1 s -2 (office
/ - 2 P I ✓ /" � L //'C.. A ' "' ; 'l.� / Q tAi use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ,--- v
(Name) R° 3 1 ' VL ��� 1—C (Phone) (.," L - ), 2 -0
(Address) I S ) 50C_ i"'C 4t. /91 /v im /
APPLICANT HP-L-5 — 1 -L'73 _ 33°1
(Name) 1 l7L 0 N (Phone) (p •) 1
(Address) 2 t0 ( t 1 l A.rl kl, P 3 St) l -4.‘: U1 /ki 53) l 3
(Address) (City) (Zip Code)
(Contact Person) O L l A ii � �� r (Phone) /r (O �l - L 3 e - 3305
APPLICANT SIGNATURE IRMA� DATE ()/1/
• ' ' LICANT P - SE COMPLETE BELOW
[NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants ❑ Steam PLEASE NOTE:
['Gravity ❑ Hot Water Air Conditioner Units
❑ Mechanical El Radiation Cannot Encroach into
❑Air Conditioning ❑ Special Devices Required Side Yard
[Went. System 111 Other Devices Setbacks
FIREPLACE MAKE AND MODEL _ ' f N J - 6 - c(-) G a 4,A) — i - .3 3 S',-)
FEE SCHEDULE
Industrial, Commercial & Multi- Family 1% of job cost Residential, Gas Fireplace $39.50
$39.50 minimum
Residential, Heating & A/C (New Construction) $99.50 Residential, Additions & Alterations $39.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $39.50
Estimated Cost $ Building Per it #
HEATING PERMIT FEE $ (014 if 1- ro
STATE SURCHARGE $ •5,0?
TOTAL PERMIT FEE $ 91 Sl
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 514 c o eipt No. � O
Buildine Official Date Date VV , I(
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245