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r Rr CITY OF PRIOR LAKE ✓ Date Rec'd
N �� HEATING /AIR CONDITIONING /FIREPLACE PERMIT 9, /3,10
Q 117
R
1. Pink File PERMIT NO
2. Green City • / O s/�
3. Yellow Applicant ` // 0
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Mal - tbi)aki 11--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name)
OWNER Dret 11 O&5 (Phone) 05a- -496 --ci 881
(Address) 143 --1 Not, Io Ck c
AP 1 Z:ti4 — t A,OisAt 1J ( Y mop- , M_4101)
(Address) Varolb' Pia— �� i �-4,CN I S5102.-
A ddress) 1 (City) (Zip Code)
(Contact Person) thn i „, .: _ a 4 (Phone)
APPLICANT SIGNATURE _'.�/% .$ _` 0 1 1 ATI DATE lig p
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ,.REPLACEMENT ❑ 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.
❑ echanical ❑ Radiation
Air Condition 0 Special Devices Fireplaces with Box Additions or
Vent. System 0 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 $ r . ' •
STATE SURCHARGE $ .11$ `'56'
TOTAL PERMIT FEE $ 'l . Z
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 51 ,.. s--70 Rect No. C j - _
Date / /�
Buntline Official Date
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
*