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01 rxro4? CITY OF PRIOR LAKE Date Rec'd
HEATING/AIRCONDITIONING/FIREPLACE PERMIT
t aLig3a . X5/ 5
1.Pink File
41tNNEso�P 2.Green city PERMIT NO. �� /�
3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
513®/ t/e-a-_‹ 0.1-4 • i 1)--%- i- 1.e'kc .
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER )
(Name) i/1„; Z. % �'- r4e. (Phone) � 6 j? a 9Fe•
(Address) 113e1 1,l4.ego AiI $r1. rio:;;:-/Loiegt. /1.0 '
APPLICANT ``-.h�t Y a 1 t.E,
(Name) (Phone)
(Address)
7402 Washington Avenue
(Contact Person) Eden Prairie,MN 553444 (Phone)
APPLICANT SIGNATURE 1A _.L/ _
DATE a1._s`1 Y
A PPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTIONZEPLACEMENT ATIONS
FURNACE MAKE AND MODEL a yJy meg. 34,2 ['ALTERATIONS
Fkrt
FLUE SIZE RETURN OPENINGS 6,QG INPUT OUTPUT,5 (960'
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
0 Air Conditioning 0 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&AIC(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 $ 49-.5'0
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 50 •
at I
This Application Becomes Your Building Permit When Approved Paid I iv ipt No.
I Es
Building Official Date Date t.-2/,c 1 I
24 hour notice for all inspections(952)447-9850 '
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372