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rR!O . CITY OF PRIOR LAKE C Date Rec'd
0; HEATING/AIR CONDITIONING/FIREPLACE PERMIT 10, Ig, i3
stIA'NEsoo 1.Pink File . J
2.Green City PERMIT NO/ /
—631
3.Yellow Applicant ! ✓ /L
(Please type or print and sign at bottom) ��i"�]�
ADDRESS ZONING(office use)
\'1s3g skArcy ' ,)-,c , m T,' 1
LEGAL DESCRIPTION(office use only) �C KJ
/ 9/CI� `'�
LOT,2-BLOCK 3 ADDITION `� � - 1W - PID 075;340 4/3-0
OWNER �a. \1� �_1 �kclL \(Name) . r (n
(Phone)Qi-S -440Z1-r) c_c
(Address)
APPLICANT - l
(Name) j► V�`Y�Nk.), ,,,__Li.x. (Phone) �� o� `"1 u�-��t�+"�
(Address) , Vt1-1 V.10\ l(Jp-k_ cY t. Q 1-141(11 55'3-.) ,
(Address) (City) (Zip Code)
(Contact Person) C\h` � 1(Phone) -I1 4-'1`1 - (41y
APPLICANT SIGNATURES - lei DATE %0 - , - I
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
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑Steam Units and Fireplaces Cannot Encroach
['Gravity ❑Hot Water
❑Mechanical into Required Side Yard Setbacks.
❑Radiation Fireplaces with Box Additions or
[kir Conditioning 0 Special Devices
[Went.System 0 Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL 1 t
'K',t ") Sv►,q pk y ,A, v' \��� Y E55E SCHE99 DIILE L 1 1 0 b.--1,1,1 i3 p
Industrial,Commercial&Multi-Family 1%of job cost Residential,Gas Fireplace $49.5)
$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 $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ Cl S/
STATE SURCHARGE $ 5(5O
TOTAL PERMIT FEE $ 5 4
(Office Use Only)
This Application Becomes Your Building Permit When Approved 41.
' ' .SD Receipt No. l
01
.teBy
Buildine Official Date 0 . \(6,1
k-5 5 ..-
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372