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fle:nro 4 CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT ,r
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�_� 1.Pink >±ile PERMIT NO. ,/ CJ's?5. i
2.Green Cily `�i
�NNESo�P 3.Yellow Applicant ( '
(Please type or print and sign at bottom) ZONING{office use}
ADDRESS � � 1:01q-J
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LEGAL DESCRIPTION(office use only) fj
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LOT 4 BLOCK 3 ADDITION -7#,Z,„ 0j,JL PID p?jr–
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OWnNe R g VThW161 (Phone)
(Address) 11/4' Jf eA - P'1 —
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APPLICANT ' -- V� (Phone) 1 2 ' 1— 1 • -1
(Name) , ����U r t
(Address) -: �r� ±,
G141I0 Mf
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(Contact Person) Phone) / .l • I —
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APPLICANT SIGNATURE i�
i DATE q- --H-/i- -
' --, PPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION RREPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FL —
INPUT OUTPUT
FLUE SIZE RETURN OPENINGS
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
r•�Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
❑Vent. System 0 Other Devices Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE $49.50
Industrial,Commercial&Multi Family 1%of job cost Residential,Gas Fireplace
$49.50 minimum
Residential,Heating&A/C(New Construction) $149.50 Residential,Additions&Alterations $49.50 AC Only $49.50
ngetaResidential,
Residential,Heating Only(New Construction) $64.50 Building P
Cost$ e
HEATING PERMIT FEE $40i•90
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ e et 0 i,
This Application Becomes Your Building Permit When Approved
MEM Receipt No.
Dat A I By
Building Official Date
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372