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6 —\ (; )-------7---- 1 01 , 'CITY OF PRIOR LAKE Date Rec'd
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/AIR CON : G /FIREPLACE PERMIT
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41 . 1. Pink File
INNESO PERMIT NO. 2 _ zy
3 . YeIIo w Applicant City
3. Yellow !/
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS r1ar Lare M
q
ior \OO:\ 5 —7.7.--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( N ) R Don 51 GoeK (Phone) 62.-1-1i173 1
(Address) Li yl(0 vnor 1 St pvvy \ 631
(Name) CANT. &A V , ' II _ � (Phone) P r t ffI
(Address) grill �/ _
` (Ad.. ess) (City) ( ip Code)
a 1 1 (Contact Person) ' ; ''. (Phone) j 1 — 1 1 1 7
APPLICANT SIGNATURE ingait.1,11, ,. DATE I lY, VO 1 I
APPLICANT PLEA COMPLETE BELOW
❑NEW CONS RV ION PLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL CN,� E 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
❑Gravit ❑ Hot Water into Required Side Yard Setbacks.
PWIli echanical ❑Radiation Fireplaces with Box Additions or
lal Air Conditioning ❑ Special Devices
['Vent. 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 $ ANIMMI1-1
TOTAL PERMIT FEE $ Minim _
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5 4` `
b Re t No& 4 l � c-
Date I v P • r f �. B �
Buildine Official Date N-
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372