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CITY OF PRIOR LAKE Date Rec'd
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,� � HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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I. Pink File PERMIT NO . yl
3. Y . Green City
Applicant / j / e t) ` / 7�
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(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER m -Ise) /��l � c �
(Name) o �t� ' - ✓- -� -� (Phone) LO (� ""'I �i�J�]
(Address) '(0-1L6 4 Jt Lit Aft ' ( PA L On ss?1 �,
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(Name) %. _ l . AA/ " I _ , 1, 1 F C (Phone) `ES c-0(_
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(Address) )US w I ()*\) \ 1 'f • tw _ 4 120 1 tc , S 3
(Address) (j ( ity) (Zip Code)
(Contact Person) . na. (Phone) c ) '1 Li -Gun5
APPLICANT SIGNATURE 6tfia._ DATE 3 - -/ 6
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION .REPLACEMENT ['ALTERATIONS
FURNACE MAKE AND MODEL 4 t 4. . .L i . F_I , FUEL
FLUE SIZE S _ ' r J 1 1 PU 1(p, J ` UTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravit ❑ Hot Water into Required Side Yard Setbacks.
g Mechanical ❑ Radiation
fgjAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
EVent. 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 $ ( ____ rrte Building Permit #
HEATING PERMIT FEE $ 1 '4 ° 1 JED
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ , f,)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid �, d o Re e pt No5“
Date3
Building Official Date / B 10 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372