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rizlo CITY OF PRIOR LAKE Date ReedE, x s e HEATING/AIR CONDITIONING/FIREPLACE PERMIT q / l
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1.Pink rate PERMIT NO. /41 f/ D
'�iNNEso"�� 2.Green Cit}' (Q
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
2-1c'1$ 7-rlMc,vi' I\\(e_ tv .1 < e)vy.->Cr ,CvAN L5c:i1}`) 111 52)4
LEGAL DESCRIPTION(office use only) l
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LOT /6/BLOCK 3 ADDITION ae./17/)7 3 AP, 0 PIDa5- 4 tiV-ao,-
OWNER
(Name) c\c n? S-\r, - ce. (Phone) —
(Address) 2.Pi cC (Pdrivsadv Avre, 1!I\N 5`-v;,,ko\ ;c , UU\N '-5---.)31'i
APPLICANT I
(Name) f,Nekiczt.A N‹, e iv'r S (Phone) _
(Address) 2/.274,12/3 j5rl i Oax 2d 1 i`op)f'. n(, V1AAi 553,-13 —
(Contact Person) )'cr-„j i4 t Ll (Phone) —
APPLICANT SIGNATURE i.,^,,.a ii:::(--, DATE 9/2)//e _
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION 0 REPLACEMENT IALTERATIONS
FURNACEMAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
El Warm Air Plants ❑Steam Units and Fireplaces Cannot Encroach
❑ ravity ❑Hot Water into Required Side Yard Setbacks.
echanical vea�' c Y "_' ❑Radiation Fireplaces with Box Additions or
❑ a1 Conditioning
- ivr, Za4 \;n- _ l
❑Special Devices Cantilevers to the Outside of Buildings
-Ll Vent.System - DOther 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 $ ,ciO
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ c'--(-, O c0
This Application Becomes Your Building Permit When Approved ctiL6k
Receipt Na. �a` 17 1
1
Building Official Date ate (A c(.1),
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By
SI I
I
24 hour notice for all inspections(952)447-9850 i
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 ,
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