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4 rRl CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
u r I m
1. Pink File PERMIT NO.
'INNESO';P 2. Green City
3. Yellow Applicant r � 1
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(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 f C W:TN W /u t.i e e
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) / a y i %.,� r 7 (Phone) (p/� - 3 �� - > 5- -�'
Name L v Gt
(Address) fb1P 3 . r.() r i le te/Le of .5f 1 /' c.. f ..a (�� ,it / U 5 - 7 2
APPLICAN
(Name) ,- ate j' e__ .. - (Phone) `15;-- `� /_ /GQY
(Address)` /4 (-fief/ ti / r� ••/ /ft/ i� f/ i s�4-' S` , 4✓ (f
(Contact Person) tr -4 L -11 _, (Phone)
APPLICANT SIGNATURE ` i .4 /1jr' DATE I '_ 6 --/1/
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION J1 REPLACEMENT CI ALTERATIONS
FURNACE MAKE AND MODEL/ 0 t/t) /9--A-4 e G (yCY 5 FUEL /U :T"3e
FLUE SIZE 7 PUS-- _RETURN OPENINGS INPUTZ:el, ? ' OUTPUT, F
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
2Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity DHot Water into Required Side Yard Setbacks.
1 1 Mechanical ❑ 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
FEE SCHEDULE
Industrial, Commercial & Multi Family 1% of joh 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 Constriction) $64.50 Residential, AC Only $49.50
Cost $ Building Pertnit#
HEATING PERMIT FEE 5 q 4 1 5
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ i, 4 , £j7
This Application Becomes Your Building Permit When Approved Paid j - j --7, Receipt No. `� /
Y,
Building Official Date Date ltJ B f ^.�
24 hour notice for all inspections (952) 447-9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372