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( . --- 1) RI? C OF PRIOR LAKE Date Rec'd 7
" °` H ATING /AIR CONDITIONING /FIREPLACE PERMIT IZ,,I 4 - ()
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1. Pink File / 0 1-7
„.s.,Z 2. Green l PERMIT NO.q
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
\ f3 c-t T -Nt \wYS kt E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWN S �ki C) e ( � l_-f 1(I v (Phone) S " 21 - TA))(/ �/
( Address) , LQ5 1 1 ut kA ,u 1-S AVC SE
APPLICANT C -000 -)
(Name) (Phone) l L
(Address)
(Address) (City) (Zip Code)
(Contact Person) • . (Phone)
APPLICANT SIGNATURE _ ' 11 kt DATE
APPLICANT PLEASE COMPLETE BELOW
LNEW CONSTRUCTION VI VI REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL C� A , (4 Ih 'AAV O (1)4 FUEL + Co, 3
FLUE SIZE RETURN OPENINGS INPUT - 7( - ",i WO OUTPUT /WO
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
❑Air Conditioning ❑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 3(49.50)
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $ 9 t so
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ )` ',-. (
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Vi.) Rece No. J /
Buildine Official Date Date iZ - 1 *. L1 7 y ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372