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H id wi y 14 SL/ .S°
CITY OF PRIOR LAKE Date Rec'd
°4 . e HEATING/AIR CONDITIONING/FIREPLACE PERMIT 2,z ' 4
6 ttyr 1'il
I.Pink File PERMIT NO.
4,I__._. � 2.Green City M ti /��
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS i J 3-7 s• C hzstii u+ Lail f"jc ZONING(office use)
LEGAL DESCRIPTION(office use only) IllLOT BLOCK ADDITION eA1p� l i, L J -- ,A J PID a6.-- 3/% —OZ/ -D
" 1
OWNER D(�v i Cl Sc E bq Q l `f 0 —2-v-i 1
Name `{Phone) g
(Address) LI 5 C S �A Lap C N) l
APPLICANT R\tur\ q Z -7/„ /WC
(Name)_ �.�Z "
(Phone) lJ ll�� [
(Address) L-Z0Q [ ) V�,u sVi l '�_
,�
(Contact Person) r�l,,�, L, (Phone)
APPLICANT SIGNATURE 111% Brdeke. DATE S I 1 ci I I L'
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION K PLA EMENT ❑ALTillS R TIONS
FURNACE MAKE AND MODEL '
FLUE SIZE _RETURN OPENINGS I,INPUT F'-ELO PUTT)/000
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
OWarm Air Plants ❑Steam Units and Fireplaces Cannot Encroach
Gravity DHot 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
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 $ LA SO
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 541 .SCS'
This Application Becomes Your Building Permit When Approved
Ili 6'1A Receipt No,(1 d
c il
Building Official Date to 912 0 By lk
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372