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PRIpCITY OF PRIOR LAKE ~' ° l ate R•c'd
.0 HEATING/AIR CONDITIONING/FIREPLACE PERMIT
U tri
MI lP 1.Pink File PERMIT NO.
NNESo 2.Green City 1 9
•
3.Yellow Applicant , '_s'.
(Please type or print and sign at bottom)
ADDRESS - , _. ;,.ZONING(office use)
, 153-Q3 , :_Jeffr* s it, .,s : , - _ - ' . _ , . - .- ::: .. f- ;-_,
LEGAL-DESCRIPTION (office use only) I
LOT BLOCK ADDITION PID
OWNER
(Name) il I tar I . . A & clone) U1 l Z' -700-7i-79 -
(Address) , 03 £ i-i/S Pass
. dt - -Y _ *;. �. ._- _ -.7.. z '. ,. ,•_ --�;- ,-b',.J--..u+ss�J-.-..:,e ...q.azn. .r_Y ...._�.L_rM.v._4 _ ..< _b.`+.w -M
APPLICANT
(Name) a iv iltALI, I--tom 4 Priv- (Phone)______WW;;; Eg4:5_
(Address) ) 9 04 \e if MI. 1 l i O S+) V HC(5fiYC , VV'7 .S.S���J
(Contact Person) 1 MCP tirs (Phone (4951 - 4 3'-1 - q)-71
APPLICANT SIGNATURE 1Z fJ ] DATE sf fj h Li ,s
APPLICANT PLEASE COMPLETE BELOW , -
- ONEW CONSTRUCTION , ' PLACEMENT ❑ALTERATIOI' S ,. :,'
F1 RNACE MAKE AND MODEL (70 Uctmak-, FUEI a ' 0._ - .#_ 4 :: -;
FLUE SIZE RETURN OPENINGS INPUT : ' ' _AL !4::+, P _.,,',,,,,: _ 4
TYPE OF SYSTEM HEATING OR POWER PLANT , I'd - _ r e.�
� ' � "NOTE:Air Conditioner
0 Warm Air Plants ❑Steam f:
r fJOs and Fireplaces Cannot Encroach
❑Gravity ❑Hot Water ififo Required Side Yard Setbacks.
t 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 job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential,Heating&A/C (New Construction) ',149.5► Residential,Additions&Alterations $49.50 .
Residential,Heating Only(New Construction) ',s i. I Residential,AC Only $49.50
Cost$ Building Permit#
- HEATING PERMIT FEE $ 'k. `n D ,
.-' - STATE SURCHARGE ' $ 5.17 ./ ,'
p; . _. .,.:.,. L PERMIT FE
- TOTAE - $ A . , ' -
.`Tll<IsApplic tion Becomes Your Bt ild lntg Permit When Approved - Paid J Receipt X30."
Building Official Date Date�-/,c// By(� „y'
24 hour notice for all inspections(952)447-9850 1
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372