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CITY OF PRIOR LAKE '' Date Rec'd
� e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
0 �
P . 21 P Gr in een City k File PERMIT NO. 8_ jNNESO� . ,r-/1[
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS . ZONING (office use)
Ukki0dW S t 3 03
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER C v C c \ C k (Phone)
(Name) � ��E' U l T
(Address) 1.,. - tO l-; LvE'...)r" , SI —SE, jD,:__
APPLICANIIT __ ‘4.- � Z L i C 1 1 'Z -- 9'l
(Name) L.) (COi t i ` - F �'"�Q_ (Phone) �,
hone) 7 1-
(Address) 1 � E- (t �CY -- CNA0 D -�'" ( K� �CiC',M V� -) 3S- Z .
Address) (City) (Zip Code)
(Contact Person) Y c-,,4 V\"!!S `----■ ' (Phone) S 'J `'''' 6 ---_
APPLICANT SIGNATURE V` v `--t_ DATE )
APPLICANT PLEASE COMPLETE B , LOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ►1 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 ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
['Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
[Went. System ❑ Other Devices
` � Require a Building Permit.
1 FIREPLACE MAKE AND MODEL Tj C 14 0 ` . j 'S ._`�� e l ', "')S`'
- mil 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
The Minnesota Statutes § 326B.148
lost $ Building Permit #
"SURCHARGE" has been extended 50
,. 0, SEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is ° 5.4i3 COTAL PERMIT FEE $ ,g0
This Application Becomes Your Building Permit When Approved Paid Receipt No. I y / 3 i
Date 67/ ,(/ 3 By 9 ,4_,‘,/_>_— Buildine Official Date /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372