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04 rRio�� CITY OF PRIOR LAKE Date Rec'd
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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�INNES�SP 1. Pink File ` ...���///
2. Green City PERMIT NO . j� � j� � p /
3. Yellow Applicant � �J �� �
lease e or ' t and si at bottom
ADDRESS ZONING (ofleice use)
►53(�D Shroe��� Ci r N �
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
o�R � �� y�
(Name) rr�►s � ,�I�h -�am (Phone) �. , -
(Address) ' � r C�r N �
APPLICANT q l 1 1Q�
(Name) f ��nnP�(�`�j .� (Phone) ��' y `l�S `�O�
(Address) � � � ` l.� `.J�CJ b (
(Address) (City (Zip Code)
(Contact Person) `J � � � (Phone) � � " � `'GJ �� �
APPLICANT SIGNATURE , , DATE �� — �2
APPLICANT PLEASE 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
ir Conditioning ❑ Special Devices Fireplaces with Box 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, 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 $ � � �V
STATE SURCHARGE $ -56' S.Cb
TOTAL PERMIT FEE $ �') 5u,�
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid �� Receipt No. // 7
(0 d /
Date ��/� /�� By
Buildin¢ Ofticial Date �
24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372