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O' P R 1040
CITY OF PRIOR LAKE Date Rec'd
4, AN pc HEATING /AIR CONDITIONING /FIREPLACE PERMIT
f kN E5 0,s
1 . Pink F PERMIT NO. _ di 7 3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / / ZONING (office
l� (,
7 rb o Ni) ' 1 j� ( I1 � ✓t') 6 c -k- i"-5-
"- use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER i I - `mil Lv�
(Name) 'J I (Phone)
(Address) L A( i0 L W �QJ lJl v C Ci 'L /'t/
APPLICANT
(Name) HEARTH & HOME TECI INOLOGIES (Phone)
dba FIRESIDE HEARTH & HOME
(Address) Lk BC662656
27f)0 FAIRV1FW AVENUE N
ROSEVICLEIPMN 55113 (City) (Zip Code)
(Contact Person) 651.6 3 (Phone)
APPLICANT SIGNATURE MP � IIII - DATE
C1L41I
°APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION O REPLACEMENT eT 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:
['Gravity ❑ Hot Water Air Conditioner Units
❑ Mechanical ❑ Radiation Cannot Encroach into
❑Air Conditioning ❑ Special Devices Required Side Yard
❑Vent. System ❑ Other Devices Setbacks
FIREPLACE MAKE AND MODEL / / / V 7 C > 5 j l c 5 (, -' 5
FEE SCHEDULE
Industrial, Commercial & Multi - Family 1% of job cost Residential, Gas Fireplace • $39:1(r'
$39.50 minimum
Residential, Heating & A/C (New Construction) $99.50 Residential, Additions & Alterations $39.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $39.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $
STATE SURCHARGE $ 50-''
TOTAL PERMIT FEE $ 'S -.'
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid K 5 / 6 - 6 Receipt No. 9e U/
Date /'�" Vat. 3 By /
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 l