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r RIO CITY OF PRIOR LAKE V Date Rec'd
°Q a> �� HEATING /AIR CONDITIONING /FIREPLACE PERMIT 6. 1, l d
t ha ':,,,
N 1 Pink Fil h
r NNES� 2. Green City PERMIT NO. / , 7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/3?2s f k'e. LA. ke a" )
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) • 1 < e i a0
ame e e kif l i e /' l i h .3 (Phone) " /'Y(5 - - C5 aa.4
(Address) �' �,S' P..- it-- e �a e / r'a 1 P! ` i' D r i c. ke,. 177 AO
APPLICANT //_I_/ , � J �U
(Name) Ou a. I.` � 0 1°.F ' 1,3 r /7l R. V P r v j c vc rt (Phone) 9 `- ) d/o 3 - y l 1
(Address) /a C '1 i V ern Tzc re,_ (I, t. 4 r f al ha -k--o p r e. S5- 7 �J
/ (Addres (City) (Zip Code)
(Contact Person) l6 , Q 4 o / e Z . (Phone)
APPLICANT SIGNATURE 4 ` Z DATE ° 1 _.1 o
il
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION EKEPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
DWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Ms..b4nical ❑ Radiation
it 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 #
HEATING PERMIT FEE $ <j 9. SV
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ SD 'OD
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid _ a Ree No a_5 0
Dat
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
If •
4646 Dakota Street S.E., Prior Lake, Minnesota 55372