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4 pRlp CITY OF PRIOR LAKE Date Rec'd
� �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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`7INNESO�� l. Pink File
2. Green City PERMIT NO r`� ' �"'1
3. Yellow Applicant r` li°
Please e or 'nt and si at bottom
ADDRESS �, �, 1 ZONING (ot�'ice use)
` l%V
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNE � ` �/�
(Name) (Phone)��' �7J� ��Z
(Address) u��
APPLICANT
(Name) e n ���C�nn�tl4n� �n� (Phone)
(Address) 13'13 Danota Cr
Shakt�s� c�l cz�p coa�>
(Contact Person) 52 5-4803 �P/' �phone)
APPLICANT SIGNAT DATE ��/ I�
APPLICANT PLE 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: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ Special Device Fireplaces with Boz Additions or
❑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, Heatirig & 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 $ .js9'
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid � � eipt No. j_��
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Date /� i �
Buildin¢ Ofticial Date � � �/ . � '
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minuesota 55372
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