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PR r °� CITY OF PRIOR LAKE Date Rec'd
N g HEATING /AIR CONDITIONING /FIREPLACE PERMIT
NNEgo
P een Fiilry e PERMIT NO / f (0Z l
2, G
3. Yellow Applicant
(Please type or print and sign at bottom) ZONING (office
ADDRESS VS \1 C;1 I use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) A ( e tf t') (Phone)
(Address) 1 ti6SC '"C/3 (J
APPLICANT �M (Phone)
(Name) 11010�IN.
times MIXON
(Address) MIS i.
less)
(City) (Zip Code)
(Contact Person) 3DCA _ I,r \ (Phone)
APPLICANT SIGNATURE �� ' DAT 1 __W U
A'PLICANT EASE COMPLETE BELOW
ANEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE (t RETURN OPENINGS INPUT OUTPUT 3
TYPE OF SYSTEM 1 HEATING OR P PLANT
❑ Steam PLEASE NOTE:
['Warm Air Plants
❑Gravity ❑Hot Water Air Conditioner Units
❑ Mechanical ❑
Radiation Cannot Encroach into
Required Side Yard
❑Air Conditioning ❑ Special Devices Re 9
❑Vent. System [II Other Devices Setbacks
�^�
FIREPLACE MAKE AND MODEL � PM n r lS 11P - 5 . 7o 4
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 Permit #
HEATING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 1.
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid , / rn Recei t o. („ 4224
Date / S ( By
Buildine Official Date i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245