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� HEATING/AIR CONDITIONING /FIREPLACE PERMIT
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4 tii'NEso 1. YPink r C it y /0 Ut PERMIT NO. y�
3 .
3. Yellow Applicant ( 1 �.�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
7'7 0 CROW Fti(r1n S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID '
OWNER MAW) C ► ` ' I� ° 1 (Vt O51i (Phone) `�`/ 1 Z Z 1 L 1 �/ 6 I
(Address) j - 7Z0 . Cardinal Rale I r e f pb
(Name) I VO I � Me I l ! ( i ( hone)
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(Address) 1.2 O[ ri 5rar0 � V � 1 � P 557
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j (Address) i L� (Zi Code)
(Contact Person) Li ► A (Phone) 3 l 1 J
APPLICANT SIGNATURE & , 0.41. DATE q' I I ` 0
1
APPLICANT PLEAS , COMPLETE BELOW
❑NEW CONSTRUCTION 11 • EPLACEMENT ❑ 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.
Mechanical ❑ Radiation
it Cond lb, Fireplaces with Box Additions or
0 ),.
g ❑ 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 $
STATE SURCHARGE $ . --36
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid � Rey • rt No , ag/
Date---,, Z d . ( a By
Building Official Date / •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372