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c).4 PRIo CITY OF PRIOR LAKE � Date Rec'd
A - HEATING /AIR CONDITIONING /FIREPLACE PERMIT C - /0 .
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�� � i. pink File PERMIT NO .
NNEs 2. Green City
3. Yellow Ap plic ant
' - _ _ _ : - . .rint and sign at bottom)
' ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
„OWNER A
(Name) HA]dQr Re c-r- (Phone) G / 2— 251. -0a ' ?
(Address)
• ' ' ICA
(Name r t O t i_c. 4/ L— ('ore
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A -i. I dress) - •. .. ' ov K- C P i • r 'WA/ S 3? 1,
► = • ntact Person (Phone)
4 •. 'L - 1 SIGNA 0 ' _, . .1 `.�. ` DATE C —h —`3
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT [I ALTERATIONS
FURNACE MAKE AND MODEL i.ripr FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
arm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑ Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
i2 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 $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Cost $ Building Permit#
HEATING PERMIT FEE $
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 1
10 /
This Application Becomes Your Building Permit When Approved Paid ISIE Rece /No. '
/ j r
g Date /0 1 gy
Building Official Date l I •
i
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372