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CITY OF PRIOR LAKE Date Rec'd
,‘
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
'etNN E S(5C
' Pink File PERMIT NO.
3. Ydbw• Appbcaat
0;-*C-7-1
(Please type or print and sign at bottom)
ADDRESS IlyWG7lofficeam)
5 5/D Ani blf't vOd D/Z Alt- PriOv Z- (ke
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER $ S -eisto-q-d4-7
(Name) 7 �f f Bal(64 iTt e (Phone)__f qs 9- gSO 45 53'�
(Address) Armilletioottl pg �)
APPLICANT (/ I . (� 7 �7
(Name) t c Vb Kite 'T ' (Phone) �.5 ' I ,0 21 O� /
(Address) s('e a ve_
(Address) (City) (Zip Code)
(Contact Person) .T C 1'(2 l�-(/I( 9k'� (Phone) C ! goo Lib 47
APPLICANT SIGNATURE "13DATE 3-5- 201
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation
['Air Conditioning ❑Special Devices Fireplaces with Box Additions or
❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE 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 $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ Lig co
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 51. CO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5q.e,0 Receipt No. 7 70
Bu;lain¢Official Date Date .3/5//5 By n_1 oL J