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A 4 CITY OF PRIOR LAKE Date Rec'd
N HEATING /AIR CONDITIONING/FIREPLACE PERMIT 8,2_,1 1
4.4..s.
I. nk File
G
2. Green City
PERMIT NO. it 0.3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4 , 1 7 9 ` C 4 W Z411e84
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER / , l - g . (Name) id E � D 6e‹ (Phone) / s.2 ' JL 7� 4i
(Address) // 7q ° <lj 4 7 abl(7
F '7
APPLICANT n / / 0 , 7
(Name) I `I N 't ( 7, (2 (Phone) C4 [fa S i- /7,1 6, ✓
(Address) ' 31 81 M C i )107, S MO, C• Mk), t7
(Address) (City) (Zip Code)
(Contact Person) Call t / (Phone) k)' 0 p S'Zd r / [a�
APPLICANT SIGNATURE DATE " /I
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE 01 KA( r2(/t RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants ❑ Steam PLEASE NOTE:
['Gravity ❑ Hot Water Air Conditioner Units
❑ Mechanical ['Radiation Cannot Encroach into
❑Air Conditioning ❑ Syertial Devices Required Side Yard
❑Vent. System ther Devices �� ( — ��4 N� Setbacks
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi - Family 1% of job cost Residential, Gas Fireplace $39.50
$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 $ 666 Building Permit #
HEATING PERMIT FEE $ S 435
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5 - i. $c)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5 - 0 Rec o. 6 � /
Building Official Date Date Q. i., By '
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 ,
16200 Eagle Creek Avenue, Prior Lake, MN 55372