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o. PRIO CITY OF PRIOR LAKE Date Rec'd
9 HEATIN /A CONDITIONING /FIREPLACE PERMIT
u
1. Pink File
INNE90 2. Green City PERMIT NO .
3. Yellow Applicant / �
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 55 Oe9ciTail E 1?ic t
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER J11 vri a ( �9Z
'-
j (Phone) 7 74.3e (Address) �5 � +F1 Omega Tall 5f Lire
( N me)CAN ■" • ?^ �� C�r t( (Phone ) LI 0565
(Address) 2 V 2 , (P /7) 0 ,,1 -- 4/
(Contact Person) / (Phone) 1,
APPLICANT SIGNATURE • ! I /' l<1..4.12 DATE y — a?' / y
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION EPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL C I Ojai e V M i.1 1-A-T FUEL
FLUE SIZE RETURN OPENINGS INPUT go,6 OUTPUT 47, (0 ,0
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
❑ Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑,gravity El Hot Water into Required Side Yard Setbacks.
L *Mechanical ❑ Radiation Fire laces with Box Additions or
DAir Conditioning p
g ❑ 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 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 $ ►{a . J0
STATE SURCHARGE $ 5.0
TOTAL PERMIT FEE $ �L(,
This Application Becomes Your Building Permit When Approved Paid ,. c S - ) Receipt No. 7// 7 f
Building Official Date Date 42 By
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372