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rite?ie CITY OF PRIOR LAKE C Date Rec'd
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' HEATING/AIR CONDITIONING/FIREPLACE PERMIT
44/0,00-0- 1.pink File PERMIT NO. I • �'
4/0,00- 2.Green City
3.Yellow Applicant
7
(Please type or print and sign at bottom)
ADDRESS ( D / ZONING(office use)
C 7 f—. A,/ }1
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER r
(Name) M c A . I Lf, I, u ,,, h,u n s (Phone) (ci S d ) V/ _ Co `--/ ,
(Address' 113-3 S E 6< /e J 1L41 d _ / V ck
APPLICANT
(Name) to.-1� 0 e 71-1-) --- —V A ( (Phone) (67,1c,))8JS — 7 7 7 7
(Address) 7S b Ck.,-,___1‘,"JI, , • - 16.1A, e _ p
(Contact Person) � a rN , 1 `"i p (Phone)
APPLICANT SIGNATUREDATE / 7 /I
7
APPLICANT PLEASE COMPLETE BELOW
M — ❑NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
MAKE AND MODEL £ i2`/ 1,,i T )j b £,t\; .. d (4 FUEL E I e L
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 0 Radiation Fireplaces with Box Additions or
g ' it 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 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 $ i-1 R • S U
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ S t--1 , ,SD II
This Application Becomes Your Building Permit When Approved Paid 5 Uco ceipt No. 1 f(()
1
Building Official Date Date'r t S y
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372