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o� PRro�, CITY OF PRIOR LAKE Date Recd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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1.Pink File PERMIT NO. ►
NNESo 2.Green City
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3.Yellow Applicant f
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
S%75 Freon1Grv(Ne 1 Sty C
LEGAL DESCRIPTIO office use
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LOT 8L •4P �iIC
PIDg3lo � (9�O
OWNER
(Name) . . R.,cc o, av c,• • (Phone)
(Address)
APPLICANT
(Name) A okv-N(22cc H ti d-C1 LLQ (Phone) c -t1go S5op
(Address) t 5&75" Frct v'KY h Tr1 S f t o e
(Contact Person) B r ib.4' CG.v^ (Phone) q 5^a y go ss-o O
APPLICANT SIGNATURE / DATE Le` 31//L�
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION /REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL Cra r t e r FUEL NG-
FLUE SIZE RETURN OPENINGS INPUT 1�'s OUTPUT .SC
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
0 Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
El Gravity 0 Hot Water into Required Side Yard Setbacks.
El Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
❑Vent. System Mother Devices F -1-r,? 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) Residential,AC Only $49.50
(4.1151\1
/� v� Cost$ tw Building Permit#
p/R
/� HEAT . 4647 -- STATE SURCHARGE $ 5.00TOTAL PERMIT FEE $ ga
This A• �; ��� s Your Building Permit W en pproved tit) Receipt No.
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Buildi g • '• to a ,0 31-t t f,te $y
4 hour mice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372