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�� pRro�� CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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� '. �"� F ''e PERMIT NO. �
2. Green City �/• ��
3. Yellow Applicant f
lease or ' t and si at bottom
ADDRESS ZONING (ofls�ce use)
1 l�� l 1� or��nv�cs�d
LEGAL DESCRIPTION (oflFice use only)
LOT BLOCK ADDITION PID
OWrTER �,.,,, �°��+ ( '
(Name) __'�� �� � ��z�J� (Phone) `� I�o�' T'i 1� �
(Address) 1�0�' I v.��d �� �� ^P�c l��C. ��' r
APPLI T \� .�,�r�
(Name) �J �'" (Phone) �n�J �. '[9td � ` q�� `
(Address) � � �� I ��
(Address (City) (Zip Code)
(ContactPerson) (Phone) ���" o�� [ ���1 �_
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL 1:.1UC�(Y1G�l�(1 C 1 I IC �O� CX� FUEL �;1G�
FLUE SIZE RETURN OPENINGS INPUT �� OUTPUT /pS�
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 Fireplaces with Bog Additions or
� Air Conditioning ❑ Special Devices
Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEESCHEDULE
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 $�"1, � 0 Building Perxnit #
HEATING PERMIT FEE $ �Q ,��
STATE SURCHARGE $ �'. �...f.�"
TOTAL PERMIT FEE $ Sy,$�'p
(Oftice Use Only)
This Application Becomes Your Building Permit When Approved Paid � Re ei t No.r„ � I�
V
Date f „ r I� B
Buildine Official Date l9 ��(� ''
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372