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4 P Rip CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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41lNNEse 1. Pink Fi '
2. Green City le PERMIT NO.
3. Yellow Applicant , �� 4
(Please type or print and sign at bottom)
DRESS ZONING (office use)
Dt75 s toecr sf r-m444 WW F('ior tarf
LEGAL DESCRIPTION (office use only)
LOT ADDITION PID
M 1'd Jac ! BLOC K OWNER I �"I O 1 7 �� (Phone) g 1
(Address)V (Address)V 7 5 [OVJeC($7 Ea fh kIW Frior La S5
APPLI 5 P 0 (Ph) 1 ( J
am e) (� l (Address) Old 1J / :I 5 1'(•'l f
1 (Address) ('ty �. ip Code)
(Contact Person) I ' / "1 (Phone) J 0e-C
APPLICANT SIGNATURE pY1 Palk DATE 5- 1 l I
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION YREPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE 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.
e ❑ echanical ❑ Radiation
Au Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑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
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HEATING PERMIT FEE $ • 5O
STATE SURCHARGE $ IW .50
TOTAL PERMIT FEE $ .M
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5-/m sv Rec t No. (9 / /
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Buildin¢ Official Date Date 3 — `G , //
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372