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PRIOR LAKE , Date Rec'd
( � HEATING /AIR CONCITY DITIONING /FIREPLACE OF PERMIT
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L Fink File PERMIT NO. - �t
41IA'NES `CP 2. Green City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � l �� 7 (Phone) S Z `C l� (^ Z2 7(
(Name) S V4 `
(Address) 2$ 31 \X) 1 A ,i�u " W
APPLICANT
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(N ame) DIAL 1 I1:T1.- ,A-C/jd11 - kite' (Phone) U - 431- 3gOl
(Address) ) 9 N. , ( c 111 on Oast) VlC
(Address) ( ri) (Zip Code)
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(Contact Person) I LI _ . /_ / j ' U (Phone) V S 1 `C -7 — 3U 6 `
APPLICANT SIGNATURE : _ i _ / L 4 .r DATE 5/30 I /
APPLICANT PLE SE COMPLETE BELOW
ENEW CONSTRUCTION /`J REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
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 ❑ Radiation Fireplaces with Box Additions or
&ilr Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
0 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 $''
Only Heating Only (New Construction) $64.50 Residential, AC On y '.49.50
Estimated Cost $ Building Permit #
q9 .SO
HEATING PERMIT FEE $ . SO
STATE SURCHARGE $ •840
TOTAL PERMIT FEE $ 5 - Sv
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid T � Receipt No. 9434
Date / , , , 3 ` j BY �i
Building Official Date ,•�/
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372