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4 FR/04, CITY OF PRIOR LAKE Tate Rec'd
o t HEATING/AIR CONDITIONING/FIREPLACE PERMIT (P, 30. / cL
u P
t 1.Pink FiledifPERMIT NO.
NNESozP 2.Green City /�, 62
3.Yellow Applicant �J
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
o47/ sa 'if Si
EsE 73 1 sb
LEGAL DESRIPTIO (office se only)
LOT BLOCK ADDITION PID075-066—0/9.. /
OWNERr
(Name) V a. ♦ (Phone) (t 1c2, ,3iI— A250
(Address) 54 rne
_,
APPLICANT
(Name) APPjanw COnnec.. ins inc. (Phone)
(Address) 1x Gh1S- 04f'F•Ivd.
WAWA MN 55379
(Contact Person) , , ;45-43 73 (Phone)
APPLICANT SIGNATURE AtiljAWA
i DATE ( G
r
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION #EPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
0 Gravity 0 Hot Water into Required Side Yard Setbacks.
Mechanical 0 Radiation Fireplaces with Box Additions or
Air Conditioning-Ruin ❑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 $49.50
Cost$ Buil 'n Permit#
HEATING PERMIT FEE $ .51)
STATE SURCHARGE $ 5. 0
TOTAL PERMIT FEE $ U;]�
This Application Becomes Your Building Permit When Approved ; ',) tki SO Receipt No. "71 +1 f ,,
Date (� By
Building Official Date W . 0. 14' 5' '
24 hour notice for all inspections(952)447-9850 ,•
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372