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� � rRr� CITY OF PRIOR LAK� Date Rec'
� ° �� Y � �'�� HEATING/AIR CONDITIONING/FIREPLACE PERMIT �
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; `lll�� I.Itink File
Z . �„ �„� PERMIT N4. `Z � �15
� l. Yellow ApplicaM
! lease e O! 'nt aAd si at bottom
� ADDRESS ZONIlVG �offi� use�
� � � � ��Q�(����Npp �.i r", �. �,
LEGAL IIESCRIl'TI4N (ot�f"ice use oniy)
IAT BLOCK ADDITION PID
OWNER ,�/ �' L
(Name) /� ,� N O ^'� e S 0 � i' � (' � (Phone)
(Address}
APPLICANT �/ p�
(Name) ��t P �' ro � C'Q � = N GU `�� � � (Phone) �'� � ' �� 7 ` � � � o ,
cA�a�s� 6� a �' i.� � � �C1 ��e. r� �, �/'a.�. /� ,� � s � o y
caaa�l cc�ty) cz� coa�)
(Cantact Person) �VIEi � r (Phone) �� v�` �� y -' l � g' �
APPLICANT SIGNATURE DATE l ` �0 - �~ — � �
APPLICANT PLEASE C�MPLETE BELOW ,
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS �
FURNACE MAKE AND MODEL _�r y� �I I'� jg,�0 p�O ,�I � FUHL �`�/G 7•
FL,UE SIZE � A � RETURN OPENINGS � INPUT tSp., oop t7UTPUT � O r,7
TYPE OF SYSTEM HEATING OR POWER PLANT ,
(�Warm Air Plants [] Steam PLEASE NOTE: Air Conditioner
�Graviry Units and Fireplaces Cannot Encroach
❑ fiot Water into Required Side Yard Setbacks.
� Mechanical ❑ Radiation
QAir Coaditioning ❑ Special Devices �eplsces with Boa Additiona or
�Vent. System ❑ Other Devices Candlevers to t6e Ontside of Buildings
, Require a Bailding Permit.
FIREPLACE MAKE AND MODEL � ���
FEE SCHEDULE
Industrial, Commerceai & Multi-Family l% of job cost Residendat, Gas Fireplace $49.50 �
$49.50 minimum
Residential, Heating & A/C (New Gonstruction} $149.50 ResidentiaJ, Additioas & Alierations $49.50
Residential, Heating Only (New Construction) 564.50 Raeidantial, AC Only $49.50
Estimated Cost $ Building Permit #
Tt�e Mianesota Statutes � 326E3.148
HEATING PERMIT �EE $ �, S� "S� RCI-#ARGF.:" h�s been changed I'or vne
year effcctive
STATE SURCHARGE $,� ��Z�'SfT .l,�l�� �, 3oto u��til Junc 3(1 �Ut t.
TOTAL PERMIT FEE $ ,� � Thc minlmem surcharge for a "Psecl fcc" �xrmit
{pfAceUseOnly) Is.t�',,.�, e�iening.luEy1.20ttl
This Application Becomes Your Bnilding Permit W6en Approved Paid � � Re + t Na � 7� G 6,
7 IJ
Bnilding OfficiAl Dste Da � "' �� ' j �
24 hoar natice for qll inspectioas (952) 447-9850, fax {952) �147-4245
464b Dakota Street S.E., Prior Lalce, Minncsota 5537Z