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o CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT 0 --/
InNESD�P 1. Pink File PERMIT NO . 1
2. Green City IL _/ v
'7 U
3. Yellow Applicant TL /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
�bt a Gvicen k■ 5N-S V .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER n 1
(Name) 0 \\ N trn e C 2 L (Phone) NIA
` [�
(Address) - WO `J `i '�V \ \ \\ C PA AO
APPLICANT
(Name) \ .AV Y"LS M \ YAGc + A I G (Phone) CIS z- q q - 0
(Address) 3(-I 5 I W. Y V1SY\ 1 \t Q� CSC, 120 \ t n SV I \' e- S �' 33
(Address) (City) (Zip Code)
(Contact Person) tV -Cpha l/1 ke,. (Phone) q5-2 {acq( 4 - 0OQ. S
APPLICANT SIGNATURE LSOPAAAA V/( / 41 d DATE /1 /36 ii a
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION [f REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL by \4 (\{- qapu 3p(71.I 3 FUEL f .
FLUE SIZE — RETURN OPENINGS INPUT " [ 0, wp OUTPUT 3 (Xx.)
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
DWarm Air Plants El Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
Air Conditioning 111 Special Devices Fireplaces with Box Additions or
['Vent. System 111 Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIRglibACE MAKE AND MODEL UV 1,X-V\ , P\\C. Ca \'k .S --Gt+
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 $ 5150• OD Building Permit #
HEATING PERMIT FEE $ LAci . 5-.
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ , Q X
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid U 0 Receipt No. 773
Buildine Official Date Date a/4 , ` 2._ By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372