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rRr CITY OF PRIOR LAKE Date Recd
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� A , .,„ e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
k 411Ar 1. Pink File PERMIT NO.
3. Yellow City ���
Green
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 (,,,,( r033-e_s Tr 1 SF'
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) + \ .ri -milt ` - . (Phone 44-7 — O I `Il3
(Address) apt
\r i SE
APPLICANT -
(Name) Dt � --tTh L--� lt° & —rth K1O 3 . (Phone) y..�, _ / y
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(Address) 1 1 d. -
(Address) (City) (Zip Code)
(Contact Person(, _ ■ (Phone) -- I-A - j (— 7n0 9
APPLICANT SIGNATURE04, CA . _ DATE 4-i 5 -tQ
APPLICANT PLEASE COMPLETE BELOW
I ❑NEW CONSTRUCTION g REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants ❑ Steam
PLEASE NOTE: Air Conditioner
['Gravity ❑Hot Water Units and Fireplaces Cannot Encroach
into Required Side Yard Setbacks.
❑ Mechanical 0 Radiation
❑Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
❑Vent. System ❑Other Devices
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 $ c CC(D . Building Permit #
HEATING PERMIT FEE $ J
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ SOC
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid�7 (A.,9 Re t No.
G at iy
Date / / B /
Buildine Official Date "( ' � d •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372