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o CITY OF PRIOR LAKE Date Rec'd
H� HEATING /AIR CONDITIONING /FIREPLACE PERMIT
x
1. Pink File
INNES�� Q' 2. Green City .
PERMIT NO. /L _ 7 i,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
i ,,,) !,..4 (9 ( \ 4 4. n OalS ' .. r r 1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNE'
(Name) rati,. t ... 4 11111...16. _ L i ,1 . (Phone) 5 LF ill
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(Address) 1 C3 ti lA r 0.1-AL r t
APPLICANT f ,, � . I4 1 � `n ` 4 ('7
(Name . - C a t J ` call I li I (Phone) ` l J I ` I
(Address) l it V ( IN/ \tIV` -\ ,5 r c 5
(Address) (City) (Zip Code)
(Contact Person) 4 (Phone) kj5 t" t'' ' 1 4 r 1
APPLICANT SIGNATURE - - - ♦ `r_ - DATE l_i___11,9--
APPLICANT PLF COMPLETE BELOW
['NEW CONSTRUCTION TRUCTION ❑ REPLACEMENT ❑ A LTERATIONS
FURNACE MAKE AND MODEL v Q C / FUEL \4,3.4,6 c a. `
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 0 Radiation Fireplaces with Box Additions or
'0 Air Conditioning ❑ 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 $ L A . • SO
STATE SURCHARGE $ „r, • " • •
TOTAL PERMIT FEE $ 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ` �i /• Receipt A .
Date , / By J
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 i
4646 Dakota Street S.E., Prior Lake, Minnesota 55372