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CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING/FIREPLACE PERMIT 7 S
A N
• �r�'NESOS
' . Pink File PERMIT NO Q
2 . Green City �(J • 00 0(
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
J Lj 5 3 N 5 t4o2 _ LA-4 E_ Ni--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) Jk504 M 1 H) ✓ L f' (Phone) 1 103 " 0 1 1
381- - q-i-ioa
(Address)
APPLICANT I ds
(Name) '�1 1 .� O /j /�• 1 ✓ �i li�li y Alf_ (Phone) L i 03 — 01 4 i I 3
(Address) [ q 5 311 5 /iv 2-� E__ 1- onp.., o L - k 553 72
(Address) (City) (Zip Code)
t
(Contact Person) ! A/ t C
/ (Phone) ` 2 03 — D L / / / 7 3 1 -' - 7- 1 400
APPLICANT SIGNATURE _�_I ___ DATE O
• APPLICANT PLEASE CO 1' LETE 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 ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
:Air Conditioning ❑ Special Devices
:Went. 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 $39.50
$39.50 minimum
Residential, Heating & A/C (New Construction) $99.50 Residential, Additions & Alterations $39.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $39.50
Estimated Cost $ Building Permit #
HEATING PERMIT FEE $ 4/9 50
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 50. 0 0
(Office Use Only)
• This Application Becomes Your Building Permit When Approved Paid 5-0, 00 Receipt No. 5:5-7/ 7
Date/ 7 o f By
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
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