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CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
I .Pink File PERMIT
NNESo P 2.Green City NO. 06
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
114 r 7 I F U,A‘_:-.‘ U1(k T
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT f
(Name) <, .rt. 1�6G ; N :r Lr✓ (Phone) CSt t 2-3169'4 Z 17
(Address) 1 ( U / r.s-s /CI< 14111 .,l h ?21 k 5foO 5 7
(Contact Person) (Phone)
APPLICANT SIGNATURE ri!7m=+ DATE 14 (tet i
APPLICA T PLEASE COMPLETE BELOW
ONE CONSTRUCTION 0 REPLACEMENT ❑ALTERATIONS
RNACE A MODEL FUEL
UE ,i'' RETURN OPENINGS INPUT OUTPUT
T PE 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
❑Air Conditioning ❑Special Devices Cantilevers to the Outside of Buildings
❑Vent. System 0 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 $49.50
Cost$ Building Permit#
HEATING PERMIT FEE $ 7
STATE SURCHARGE $_5_4(110__
TOTAL PERMIT FEE $
41
This Application Becomes Your Building Permit When Approved Paid 6 or No//i
Building Official Date Date G� 11- r ,
l
24 hour notice for all inspections(952)447-9850 40
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372