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of ?R ` �,� PRIOR LAKE Date Recd
7 E ' l l ifs � � CITY OF PRIG
HEATING /AIR CONDITIONING /FIREPLACE PERM IT
4 " l ArN E S C P .
21. Pink reen F Ciile PERMIT NO. /.3 9f 77
. Gty
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Ili It !„/.1Jci- •es3 Tr 4. ,S2
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) C c r # e' po y (Phone) 12.
(Address) (1 0 I
c,/. -lder" € S S 1 41. 54
APPLICANT,/ ! 5-2 — 5�s
(Name) o ^ e el," A : e d.. ( (Phone) ( (� Gj
(Address) 2 0 2 6 r J l 6 v/' �f-, 56 ,,f� ._ ? 9 /
(Address) (Cit} & (Zip Code)
(Co Person) L ;P ‘` 110 •• ,
_ _ (-301 £S'Phone) q L -qt.(J = ff s �,5._
APPLICANT SIGNATURE I 0' t DATE — �D - 13
APPLICA PLEASE COMPLETE BELOW
['NEW CONSTRUCTION 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.
Evlechanical 0 Radiation Fireplaces with Box Additions or
A ,�), ir Conditioning d kU C \ ❑ 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 Permii 11�n
HEATING PERMIT FEE $ `�" • "
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 5
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ‘___6 �1i Receipt No. 9 If d
Date (/ t By
Building Official Date Amin
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372