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o. PRr04t CITY OF PRIOR LAKE I►ate Rec'd
z HEATING/AIR CONDITIONING/FIREPLACE PERMIT 3, (o , f3--
t-) f3''
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1.Pink File PERMIT NO. /r
.151
�rY
INNEso P .Green City
3.
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS . / ZONING (office use)
-smss-w- .)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) max_ �'bs CSC 7/
(Phone) 7J-2- 7`t` – 3 7/3
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Contact Person) (Phone)
APPLICANT SIGNATURE `/ DATE ..0/.2--w1 C
APPLICANT PLEASE CO LETE BELOW
['NEW CONSTRUCTION 0 REPLACEMENT ❑ALTERATIONS
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 0 Radiation Fireplaces with Box Additions or
0 Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
Vent. System 0 Other Devices Require a Building Permit.
IREPLACE M AND MODEL 3 –�C- S
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 $ +(f.
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 5774,7)
This Application Becomes Your Building Permit When Approved Paid glow eip No. fp
Building Official Date Date 3 ja S" Q'•
F
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372