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oi 17I-1% CITY OF PRIOR LAKE Date Rec'd
o pKO r, HEATING/AIR CONDITIONING/FIREPLACE PERMIT /1 , .3, / (k
--....,,-
I.Pink File PERMIT NO.lq- 1 )
..... c7-1-1
4410itsoll' 2.Green City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
111.61 (44,-)6,.1 at 1 2-04. Lae( ow 11573
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID d-S 1-0F:31 CO
OWNER
(Name) (Phone)
(Address) 1
APPLICANT A, 1 i*iii ,
i A
(Name)_ rhn C. 5 ijiW/ -- (Phone) 95 __ Vs5--AZ3g 1
(Address) aboq a) owl 0 1 at.,reotii /I 7Li537
(Contact Person)_ irn014 ihtio (Phone) 9i -3953
_.
APPLICANT SIGNATURE r.....--"---...---------- DATE ii/3Pai9
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
DWarm Air Plants 0Steam Units and Fireplaces Cannot Encroach
0 Gravity DHot Water into Required Side Yard Setbacks.
['Mechanical DRadiation Fireplaces with Box Additions or
0 Air Conditioning DSpecial Devices Cantilevers to the Outside of Build ings
0 Vent, System ClOtherDevic • Require a Building Permit.
11:17 MAKE AND MODEL / , , - / ' 11r
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 Pennit#
HEATING PERMIT FEE $ Li q 60
STATE SURCHARGE
TOTAL PERMIT FEE $$ 451Q0
This Application Becomes Your Building Permit When Approved Paid 5 Lc c-o Receipt No:72103
Building Official Date Date By
t
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24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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