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rR10 CITY OF PRIOR LAKE Date Rec'd
3
�� HEATING /AIR CONDITIONING /FIREPLACE PERMIT
I �NESO�� I. . Ye Pink File PERMIT NO. ,�
T
3. Yellow City 1\ w Applicant
(Please type or print and sign at bottom)
ADDRESS ti ZONING (office use)
11 I —T
M r Ukh \\ Q l cl ' S I C+t ■ I
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ��>� r Vi v Ct � �� � 1 ) 31
(Name) n
1 h Y'1�r"1 (Ph
Address
APPLICANT fy\ •
(Name) -k ' 01 (Phone) 7 1 -- kr)- g) a\i
�\ I c
(Address) \ C A g `) \A i 1 (-02N).— Y (' 9 y) 0.-- e `9 S S T1
/� (Address) t (City) � (Zip Code)
(Contact Person) �' V L'�� S J,, 1 ''� (Phone) ( l c e)-Li > " b IA
APPLICANT SIGNATURE /M 1 DATE ^ a 1 - 3 b o
APPLICANT PLEASE COMPLETE BELOW
❑NEW CO STRUCTION ,REPLACEMENT ❑ ALTERATION
FURNACE MAKE AND MODEL T ci.-Nls — 5 IS Pt ° V 0 r 1 0 FUEL IV A
FLUE SIZE RETURN OPENINGS INPUT 11 (, 0 Ql) OUTPUT A > 0 --0
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
]Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
jAir Conditioning ` ) ❑ Special Devices Fireplaces with Box Additions or
['Vent. System \ ..�r R �3 ❑ 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 #
L k q
HEATING PERMIT FEE $ `��
STATE SURCHARGE $OC1
TOTAL PERMIT FEE $ S L i 5 9'
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5y 3 --6 ReceipNo.
( Z
Date j By
Building Official Date i0 / iL .f�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372