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� � '� CITY OF PRIOR LAKE Date Rec'd
x HEATING /AIR CONDITIONING /FIREPLACE PERMIT 4 . Z . 7
,. N N E 9O
1. Pink File PERMIT NO.
2. Green City $ 9 , O /1
3. Yellow Applicant (/ e
(Please type or print and sign at bottom)
ADDRESS ZONING (office se)
YSS P(Rqscfr S t-st.% f4idZ C1 /Gz.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) R Q N A I S + r) 4 (�..1 PJ aCrl ,S 0 r.,-) (Phone) (! S)) ( An - 3 a a O
(Address) 1 S 8 ( QS aix / r�ewz_. ( f ; . rl.. c, J62.
APPLICANT 1 - // / Q (�
(Name) 1L'N 4'\ fit . S TFN ( # M 1 3 (Phone) �U/ Z) g66 _ 1 / 0 d
(Address) C3 aS gL0o,..,ing 1 ON A'1>, S ov/I( I ..e L/o s - Y13 -/7(q
(Address) (City) (Zip Code)
(Contact Person) A." CO A (Phone) ( 6 / Z / o 66- II
APPLICANT SIGNATURE ` 9 1 I t cry' ` /Gn DATE 3 h o / O t$ `j
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION cg REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
p_ L4 ua TYPE OF SYSTEM HEATING OR POWER PLANT
0 co ),'""t. N ['Warm Air Plants ❑ Steam PLEASE NOTE:
Gravity p Hot Water Air Conditioner Units
A ( C. ❑ Mechanical ❑ Radiation Cannot Encroach into
1
Air Conditioning ❑ Special Devices Required Side Yard
❑Vent. System ❑ Other Devices Setbacks
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi Family 1% of job cost Residential, Gas Fireplace $39.50
$39.50 minimum
Residential, Heating & A/C (New Construction) $99.50 Residential, Additions & Alterations $39.50
Residential, Heating Only (New Construction) $64.50 X Residential, AC Only $39.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $ 1 99 -
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ S0 , 0 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid r
VU Recf . No.
9
Date � By !/
Building Official Date 4 2, •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 4 5 /
16200 Eagle Creek Avenue, Prior Lake, MN 55372