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1 0; RIO CITY OF PRIOR LAKE Date Rec'd
`� ate - HEATING /AIR CONDITIONING /FIREPLACE PERMIT 3, /' 6/
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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
(Name) (Phone)
(Address)
(Nam P r' CST ��g� N� ,N— • � ! 1 (Phone) 9 c 2 - 1 1 7 .-')) 6
(Name) / ® � � N L �,()
(Address) 6 65k 9 / ,..,LAni r . /c�� ODr "� i'.(` (i 0 r Le-gc Le-g Only vCT 3 1
(Address) (City) (Zip Code)
(Contact Person) ,- i 41 _ (Phone)
APPLICANT SIGNATURE 1_ - I►, / DATE t- Ili - d
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL 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
❑Gravity El Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
['Air Conditioning D 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 I% 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 $ 49 V
STATE SURCHARGE $ 55
TOTAL PERMIT FEE $ 54-, S V
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid C ¢, Rec i t No. (P U 4
Date i f ' By
•
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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