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O � p RIp� CITY OF PRIOR LAKE Date Rec'd
F � HEATING/AIR CONDITIONING/FIREPLACE PERMIT Q� �3 / Z
� � /
�INxESO��` '. P �"� F "e pERMIT NO.
2. Green City � y
3. Yellow Applicant
Please e or rint and si n at bottom
ADDRESS ZONING (oec7ce �)
�'�"J y Q �v�O �^r,� ct�a �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�� ��_� �t. +rl � �iC�� (Phone) � � �i � 7 J�pr (p�p�
(Address)
� PLICANT � / l!'� rfe�.'7�71+ � � 1� C (Phone) ! .s� ` �� ��� �
ame �! ,
(Address) i' - � � �c70 "�! � � �.�i'�'l���i t( �� � �1J �O ��
(Address) (City) (Zip Code)
(Contact Person) C� ✓ �' C_s� l � �� (Phone) Cd � �' � 1 � ' � �D �
APPLICANT SIGNATURE DATE � �l3 — � Z
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION LACEMENT ❑ ALTERATIONS
FURNACE MAKE AND�ODEL �/zC ��� FUEL C-7
FLUE SIZE TURN OPENINGS INPUT OUTPUT O D Q
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
OWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
�A4echanical ❑ Radiation
�Air Conditioning ❑ Special Devices 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, 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 $ �� �
STATE SURCHARGE $
TOTAL PERMIT FEE $
�offi�e use only�
This Application Becomes Your Building Permit When Approved Paid �� L']� Rec i t No. `��r�
7 �� (p �
Date� /� /� B
BuildinE Official Date � �� � �
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372