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�� p l RI �� CITY OF PRIOR LAKE Date Rec'd
� j� /( � j� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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2. Green ��t , PERMIT NO '
3. Yellow Applicaut - / �.
Please e or rint and s' n at bottom
ADDRESS � ZONING (oeece use)
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LEGAL DESCRIPTION (office use only}
LOT BLOCK ADDITION PID
OWNER ' (� /�, /�
(Name) �� �� �'f� `"���fi '�� (Phone) � � � ` � �`� — C.J ! � �
(Address) � % I
APPLICANT fy �/ ,/ (�
Name) ' li�li'IC,�C,"� Y"�" � f�. r/�L (Phone) "/'�� ' l �T� "" � 77`"d
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(Address) �:�' /S,'r)GiS�Di✓7 �, �L�L'�"7 7"�CU1'I�� ��-�`��
(Ad ss) (City) T (Zip Code)
(Contact Person) �1 v� (Phone) _ ��� � � �� � � ���
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APPLICANT SIGNATURE �/'" DATE / � ��� '��
APPLICANT PLEASE COMPLETE BELOW
ONEW 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
❑ Mechanical ❑ Radiation into Required Side Yard Setbacks.
❑Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System (� Other Devices uin - 'u.S ��•t._ Cantilevers to the Outside of Buildings
�. �{�r� C�cq„�R�.e �¢q„�.,� Require a Building Permi�
FIREPLACE MAKE AND MODEL CL,�p( `� �ne
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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 $ '7 / • � `'�
STATE SURCHARGE $ ,_� �G1
TOTAL PERMIT FEE $ , '�
(OfTice Use Only)
This Application Becomes Your Building Permit When Approved Paid �,/ ✓ 5 -vi ceipt No. /,/(� V'
�C �9 �c
Date � � ,� � � � �
Buildins O[ficial Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245