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CITY OF PRIOR LAKE LI Date Rec'd
04 rRr9 e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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1 Pink F
jNNESC) 2. Green C ity PERMIT NO. o. 0 3z4—
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
S I ieo ki, Q•J C; rz:--/
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) j ) \ GX . l X \ 1'\ ( (Phone) cLc UI 0 -
(Address) S i2 0
APPLICANT � ]� ii� �/J l )� J - y /�
(Name) � i 1 1 v C �6�l1C. !'I C�-/7 C (Phone) ►!' '7` 7! / ID / V
(Address)/ ( 9 S y Pi 1, !c. &- , 0 c+- jor i 0 ( 1,r-Fe .0A/ ss
(Address) (City) /L, (Zip Code)
(Contact Person) • � —c. AI 4 r + . (Phone) 9 1 4 7 7- t5 C� 1/ V
APPLICANT SIGNATURE Air' DATE i y —0)6/ 0
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACEKE AND MODEL FUEL
RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑ Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
E Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ ag , hanical ❑ Radiation
.11 £ Conditioning El Special Devices Fireplaces with Box Additions or
Vent. System ❑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 3 ----b . (4 ) Re • •t Nob d / v /
Date, 4- O D
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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