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.1,7A PRI ° N7:.1 CITY OF PRIOR LAKE Date Rec'd
- HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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21 Pink Green FileCity PERMIT NO. /3 4 g,2_1
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
6°76 i ti.r& C.:r St
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER')
(Name) 1� 1�... -.' ' n l�Ly (Phone) .C/52 - 00 - 6// 9
(Address) 6 0 76 .. I I .t kr\ C+ rt.k V i
APPLICAl r (� ("�_ Ws C7S-�jL
(Name) U^.) t L.0„vt..:.1 (Phone) / > O 0 7
(Address) i 1 /0 0 6 r+c k x r 1 IIL-1 . _CL 'K..► c�2- S 3�
(Address) (Ci�}) (Zip Code)
(Contact Person) L ' I �',''` (Phone) �S L ���� - (
APPLICANT SIGNATURE DATE >e-
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION [REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL PiXIA FUEL
FLUE SIZE RETURN OPENINGS INPUT P 1 ' V -- In 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.
CDAtchanical ❑ Radiation Fireplaces with Box Additions or
IMI Air Conditioning 0 Special Devices 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 $ Building Permit #
[
HEATING PERMIT FEE $ 33
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ FA. t
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 6 Receipt No.
,.,rye _3-7) 9.� �s
Date 7/ / 3 By BuildinS Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372