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� rRl CITY OF PRIOR LAKE Date Rec'd
F �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�j�'NES��P 1. Pink File
2. ��n �; PERMIT NO. IZ �
3. Yellow Applicant
ease e or ' t and si at bottom
ADD SS �_., ZONING (ottice use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�aWNER S (Phone) �[ 1 �~ V � � �-�X lL� �
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(Address) � Z�� � ��L �, �
APPLICANT � �. � ��r�
(Name) (Phone) VL�
(Address) �Zd � �� � � � l SS �
(Address) (City (Zip Code)
(Contact Person) � (Phone) J �` ' W U
APPLICANT SIGNATURE DATE 1 t�
APPLICANT P A COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIO
FURNACE MAKE AND MODEL �C� "� � L 2� �����UEL��� S
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Wann Air Plants ❑ Steam Units and Firepiaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
echanical ❑ Radiation
Air Conditioning ❑ Special Devices Fireplaces with Boz Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Buiiding 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
Residential, Heating Only (New Construction) $64.50 Residential, AC n y $49.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $ �l / . �—J�J
STATE SURCHARGE $ �. U U �
TOTAL PERMIT FEE $ ��] �(}
(Oftice Use Only)
This Application Becomes Your Building Permit When Approved Paid �� � Receipt No. � �/
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Date � d )� � /� B
Buildine Officisl Date f��
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372