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,��� pRj ��,�, CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
�
f '�'NES��
1. Pink Fiie pERNIIT NO .
2. Grean Ciry �� �` Z
3. Yellow Applicenl
Please e or rint and si at bottom
ADDRESS ZOI�TING (otfice
�;��� �����.���► ���� � � �e
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER pp
(Name) 5��/� � �� �'"'�, (Phone)
(Address) �� 1 l I����IJL 1`��vL ��
(1 PP�LI j ANT 1� l �L 5 ��L �� �' H (Phone) �p � - lO � �' - �3� 1
�T f
(Address) 2 �,� h�A �(L��L� A��S i�.. {��Ss�l�-1,�-- Ih N�.� 43
(Address) (City) (Zip Code)
(Contact Person) �G� � � (Phone) l0 � � � 3�� 33�5
�
APPLICANT SIGNATURE DATE
APPLICANT PL 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
PLEASE NOTE:
�W�'`� P ��� � S ��"' Air Conditioner Units
❑Gravity ❑ Hot Water
❑ Mechanicel ❑ Radiation Cannot Encroach into
❑Air Condiuoning ❑ Special Devices Required Side Yatd
�Vent. System ❑ Other Devices Setbacks
FIREPLACE MAKE AND MODEL � 1 ��2 /`�N J� ' 39 3 3 y
FEE SCHEDULE
Industrial, Commercial & Muld-Family 1% of job cost Residential, Gas Fireplace $39.50
$39.50 minimum
Residential, Heating & A/C (New Construction) 599.50 Residential, Additions 8c Alterations 539.50
Residen6al, Heating Only (New ConsWction) $64.50 Residential, AC Only $39.50
Estimated Cost $�1 �`� + Building Pe it #
HEATING PERMIT FEE $ �� �+l �i- �
STATE SURCHARGE $ •5
TOTAL PERMIT FEE $ '�i �
�om� u� oo�y�
T6is Application Becomes Your Building Permit When Approved Paid ��� Receip o. ���� �
Date Z 2 7 Z BY
Buildia¢ Official Dste
24 hour notice foe all iaspections (952) 447-9850, fax (952) 447-0?AS