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O . PR/0. CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING/FIREPLACE PERMIT
a
3 ‘;;. ift,__C r
M, ll 1. Pink File PERMIT NO.
NNEso 2. Green City -- 1 */ &
3. Yellow Applicant / `
(Please type or print and sign at bottom)
ADDRESS _
,c ZONING (office use)
2 7 �5 : �L - 5 / / s� .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ey/ ,0-0 4 % T _, 4, lC (Phone) 41 CGIZ' 047?-
(Address) 5 /3----e/go c / s z if!�" - i 72 6
APPLIC T /
-� : , G ( (Phone) 9,s •-I`' 41/- /0 YZ
(Name) r� � � ` - �».�.� uvm.
(Address)
7/4`)-2';- a s,6 '1, :4 .1 ;t
(Contact Person) '�'? ��'
(Phone).
APPLICANT SIGNATURE 1 J „ DATE j,3
A ' PLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION 314.1 !PLACEMENT ❑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
• ravity ❑ Hot Water into Required Side Yard Setbacks.
..• echanical ❑ Radiation Fireplaces with Box Additions or
❑ Air Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑ Vent. System ❑ Other Devices Require a Building Permit.
FIREPLACE MAKE AND MODEL(- e 9tcr9 37g V ir
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 $ 49. 3
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ .34 sr
This Application Becomes Your Building Permit When Approved Paid j1 Receipt No. 7e VI
Date / 2 By / �
Building Official Date �
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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