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o � pRl CITY OF PRIOR LAKE Date Rec'd
� 9 HEATING/AIR CONDITIONING/FIREPLACE PERMIT �, Z� � Z
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�I�'NES��� 1. Pink File PERMIT NO. I I
2. Green City /� /
� 3. Yellow Applicant �' «
lease or 'nt and si at bottom
ADDRESS ZONING (ot�'ice use)
�a�� � �?►v�.�- �� 5�
LEGAL DESCRIPTION (oflfice use only)
LOT BLOCK ADDITION PID
OWl�TER ..
(Name) xa-� � ���-�v � ,�� D �'v/ �i �r✓ (Phone) 4'S.�—� �� � � ��o
(Address)
APPLIC '/- �/� /
(Name) �; o r L QI•�C— f7'Y''S e�' �[ � (Phone) � �..�� y 7� `1 �
(Address) � � J � y �C�JJG �f?�O� (�'
(Address) (City) (Zip Code)
(Contact Person) '� /�/ C-.+id/� (Phone)
APPLICANT SIGNATURE DATE ��
APPLICANT PL COMPLETE BELOW
❑NEW CONSTRi�CTIO REPLACEMENT ❑ ALTERATIONS
FURNACE AND MODEL S F� � FUEL
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 Fireplaces with Boz Additions or
�Air Conditioning ❑ Special Devices
❑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 $ y '`J. �
STATE SURCHARGE $ �". �J17-�$--
TOTAL PERMIT FEE $ "�
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ��L� Re e' t N� 7 Z Z�
7
Date�� Z � /Z
Buildin¢ Ofticial Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372