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HEATING /AIR CONDITIONING /FIREPLACE PERML- 5 4 .50
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4NESO,, 1. Ping Pile PERMIT NO. So
f1
2. Green City �/
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
15311 Cdi hie N E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N ) Alf at IarS (Phone) "152 441- 4%0
(Address) 1 5311 ad I fl b u h A N e
APPLICANT one f — �J
(Name) ` U 1Ili F I (Phone) I 1 /
(Address) i (1O 1 Y l 1 1 1 u.) 1 a eef fklshn h 5
(• ddress) (City) (Zip Code)
A
(Contact Person) III 1 r . __ I i r IC4I I (Phone) 1 ND ^' 4411____
_
APPLICANT SIGNATURE • . N 1 A A 'Or IA / �`∎ M 2D .L � _ DATE
r I
APPLICANT PLEASE COMPLETE BELOW
ENEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL a (2-) 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
ki/1.ae vity ❑ Hot Water
into Required Side Yard Setbacks.
chanical ❑Radiation Fireplaces with Box Additions or
['Air Conditioning ❑ Special Devices
OVent. System 0 Other Devices Cantilevers to the Outside of Buildings
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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 54 _ Re/t No6 iG b j
Buildint Official Date Dat , / I t, /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372