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❑❑ ❑ ❑❑ ❑ C.) ❑ ❑ 1E
of I'RI% CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
t-, QA 61,1 7 7, t V
1.Pink File PERMIT NO. J /-
4t•NNEsCA# 2.Green City •
l k 4.39,
3_Yellow Applicant
(Please type or print and sign at bottom)
ADDRESSZONING(office use)
(c2. e e 2) P 15_,b
LEGAL DESCRIPTION(office use only) n 40/11/
LOT?-BLOCK / ADDITION '- e)di 4s gi'ome 7 PID 45.. / -190, `O
OWNER
(Name) )0)L-1 > � (Phone) p,S1 �7 -"3 th
��Il..S
(Address) I ZDO AM-T ii L 41)
APPLICANT FIRESIDE HEARTH & HOME651-633-1042
(Name) (Phone)
(Address) _ 2700 FAIRVIEW AVENUE NORTH, ROSEVILLE, MN 55113
(Contact Person) Mallory Miller (Phone)
APPLICANT SIGNATURECiet \Ce
DATE 7/4 ki
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
QWarm Air Plants El Steam Units and Fireplaces Cannot Encroach
❑Gravity DHot Water into Required Side Yard Setbacks.
ID Mechanical 0 Radiation Fireplaces with Box Additions or
DAir Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
D Vent. System 0 s they Devices Require a Building Permit.
FIREPLACE MAKE AND MODEL a ✓I s 'J')
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 Pennit#
HEATING PERMIT FEE $ 49.50
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 54.50
This Application Becomes Your Building Permit When Approved — S-0 Receipt No. i 7 i.
A{ 9_,
Building Official Date ate 1 > ` ` k By
5- 3--
24
24 hour notice for all inspections(9S2)447-9850 I
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372