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( --pRio CITY OF PRIOR LAKE Date Rec'd
A 41 ' � HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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41I A NESD ,SA 2. 1. Pink Green File City PERMIT NO. 13 _ y 9,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
S CO j /6 - a ° a .. SI/0
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �"�..t_t W G V ' (Phone) 95 . c2g3 -01 Jam-- 1
C
(Address) 0 J ___ J-e--
APPLIC
(Name) l U��v7 � (Phone) / T 7C • /990
(Name) Phone 3.
0_1;_. rt / -70
(Address) Av. / L _, . . /N / S S y `/ / - pG t/ .tf {D (,1
(Addre / (City) (Zip Code)
(Contact Person) q �`�� 1 ' — ' (Phone) �C� `T
—1 " 41 111.11 DATE S • Z 2 • /3
APPLICANT SIGNATU D
APPLI T PLE COMPLETE BELOW
['NEW CONSTRUCTION U 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
V it Conditioning ❑Special Devices Cantilevers to the Outside of Buildings
ent. 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 $ ' • S v
STATE SURCHARGE $ S , a7 hrr --
TOTAL PERMIT FEE $ ,.S y . c c)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 2 — q Receipt No. / p „ 7
1 \ 4
Building Official Date Date .x/4/3 BY
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372