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01 I'RI0. CITY OF PRIOR LAKE Date Rec'd
e HEATING/AIR CONDITIONING/FIREPLACE PERMIT / 22- /5
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ywivEso�P
1.Pink File PERMIT NO.
2.Green City Is-.
"7
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
5 307 Leiej arcte,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Name)OWNER
Y'\4 tAr i G 1 0 OeC q i 0 L t (Phone) 601e) I r r d) ?1
(Address) 530 '7 Leh'\ ley Ci`I'C(....
APPLICANT[[ JJ I. t
(Name) / Ola"\ rti t p Per C jrl�►.A (Phone) 6(e?dC 1/
,
tzt
(Address) 1(f7'8..5-- CC CC. !Are z,h
(Contact Person) 4b1.? 4 - I/I'\. (Phone) �p �C� 7 o , c71`\
APPLICANT SIGNATURE J DATE !P' .4;41)/S
---
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION ❑REPLACEMENT AALTERATIONS
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
❑Gravity ❑Hot Water into Required Side Yard Setbacks.
Mechanical i 0 Radiation Fireplaces with Box Additions or
Air Conditioning -I-17k 04 004ZEI Special Devices Cantilevers to the Outside of Buildings
0 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 $ 'v
STATE SURCHARGE $ 5.0
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid •94 Rece' No Q11
Y
Building Official Date Dat
% Z�r / B I
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372