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o� PRIp�y
CITY OF PRIOR LAKE Date Recd
- N HEATING /AIR CONDITIONING/FIREPLACE PERMIT
V - to
ry
I. pink File PERMIT NO. . . / 21 j --
2. Green City /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 7 ZONING (office
use)
\`fl" Lt MAN( i'tklL 5 C.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER G 4, Fes, ,3 (Phone) 9 j 1 1 4 01,
(Address) ' l ` i t &AV N (1 .
APPLICANT HEARTH & HOME TECHNOLOGIES
(Name) dba FIRESIDE HEARTH & HOME (Phone)
Lic BC662656
(Address) 2700 FAIRVIEW AVENUE N
ROSEVILLE, MN 55113
64 4 4.256 (City) (Zip Code)
(Contact Person) * (Phone)
hog iii(11P 1 lit
APPLICANT SIGNATURE ,6 Wk DATE ca
APPLICANT 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
['Warm Air Plants ID Steam PLEASE NOTE:
['Gravity ❑ Hot Water Air Conditioner Units
❑ Mechanical ❑ Radiation Cannot Encroach into
['Air Conditioning ❑ Special Devices Required Side Yard
❑Vent. System / ❑ Other Devices Setbacks
FIREPLACE MAKE AND MODEL 11/ ^ " ' j' i 9 , ) L 31— - ��
FEE SCHEDULE
Industrial, Commercial & Multi- Family 1% of job cost Residential, Gas Fireplace $ yfC -
$39.50 minimum
Residential, Heating & A/C (New Construction) $99.50 Residential, Additions & Alterations $39.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $39.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $
STATE SURCHARGE $ fs0'
TOTAL PERMIT FEE $ .51 5
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid , 4, Receipt No. d 8
Date By
Building Official Date / 1- /.3
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245