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� r Rr CITY OF PRIOR LAKE Date Rec'd
� �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�jMVESO�P t. rsnk File
2. ��n �;t PERMIT NO. /Z _ �
3. Yellow Applicant
lease or ' t and si at bottom
ADDRESS ZONING (office use)
I G � t'' � C.
LEGAL DESCRIPTION (ot�ice use only)
LOT BLOCK ADDITION PID
OWNER .
(Name) �b� � � � Gwy�, � �J ot (Phone)
(Address)
APPLICAN
(Name) I'�I C� r � u�� ,� �� (Phone) �.,�-���' �1 ��
(Address) ! ,� �� � �P� � � C� �!� � K �'1— �j�-%`�` i4li(/�C37 0�
(Address) (City) (Zip Code)
(Contact Person) +�-� (Phone) � � '� �2 �� � �
APPLICANT SIGNATURE DATE �O' ��I.�
APPLICANT PLEASE COMPLETE BELOW
�NEW CONST UCTION REPLACEMENT ❑ ALTERATIONS
FURNACE KE AND MODEL ���e�ly �r ,J �����,��� FUEL /(l/��
UE SIZE �� V� 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
❑ Mechanical into Required Side Yard Setbacks.
❑ Radiation Fireplaces with Boz Additions or
,�+rir 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 $ �9 .�
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ v�' .
(Oftice Use Only)
This Application Becomes Your Building Permit When Approved Paid� `� Receipt No 7 , !/�
��� 7 �
Date /� By
Baildine Official Date ��
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372