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ol iRro CITY OF PRIOR LAKE 5--:‘,)--'-::_1.3---------ffirc'd
4,0_, HEATING/AIR CONDITIONING/FIREPLACE PERMIT
°6' =i
1.Pink File PERMIT NO. l�. (57
4INNEso0P 2.Green City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
'1/‘ /o c94t CA SF
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER / . �/
(Name) 4 i'Lj�uLt.- -L k
si "� C (Phone) C9— a‘:1- 19s?c> -
(Address) :c.--//‘—i6..0St. )4 ; ri 'i*e... A) .
APPLICANT
(Name) I (Phone)
(Address)
(Contact Person) ilism
APPLICANT SIGNAT •.� ill' DATE 1.�/� ---r
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ►r4f' PLACEMENT ❑ALT ,TIONS , �/
FURNACE MAKE AND MODEL l�. ) �y ",1-4? �i-�'Ca2 :�"UEL /��'SP/"
I*
FLUE SIZE RETURN OPENINGS INPUT toseaV OUTPUT •
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
0 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 $ lig--5-7.D
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ - '�'
,t! A
This Application Becomes Your Building Permit When Approved Paid r LtM1t
'�`
Date-) I:
Building Official Date �A '
24 hour notice for all inspections(952)447-9850 •
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372