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A7 iRi ,. 1 CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING/FIREPLACE PERMIT (/‘. [ /2
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1. Pink File PERMIT NO.
4 t/NNEsol P 70* 2. Green City / •/ �j c /22g
3. Yell Applicant ((((JJJJ
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
x6 3(8 PcLSf
- (R1s
LEGAL D SCRIPTION (office use only) .. i
LOT .LOCK ADDITION S `e- Pg- /T PID
OWNER q74 (Name) S t c _ _ Pa 111s�� / (Phone) 4 5 � J' Zq / -
(Address) 4, 7,41 , „ As 144 v —'
APPLICAN
(Name) i / (Phone)
(Address A
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE / // 43
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION 'REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL (J Q r) FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
0 Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
0 Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical ❑Radiation Fireplaces with Box Additions or
Mir Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
0 Vent. System OOther Devices 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
Cost $ Building Permit#
HEATING PERMIT FEE $ s
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved , I 5 Receipt No. 'To 36/
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Building Official Date D. to I I 13 By S A___25...---
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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