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• rnro CITY OF PRIOR LAKE Date Rec'd
t HEATING/AIR CONDITIONING/FIREPLACE PERMIT /v 30,11(--
i.V s to
I.Pink File PERMIT NO.
A 3
AvtgEsdiP 2.Green Cil
3.Yellow Applicant ` �' �,
(Please type or print and sign at bottom)
ADDRESS .— ZONING(office use)
Uc,VL.5 LQ IRAQ.- \ rr 1J 3 - ?. L .
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
owNl� ,A.G - 1 1 c ) it, -3k7 --5)5o
Name Phone
(Address) 'N IX, 6„\nAtIck.._. ` \a.A1,
APPLICANT
(Name) V,A Z_I-L�- lif (Phone) —
(Address)
(Contact Person) - ek (Phone.. 112-- 5_) 193
APPL.ICANI'SIGNATURE DATE _ I O .`5 _ L4
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION NI:REPLACEM_ENT ['ALTERATIONS
FURNACE MAKE AND MODEL e G, ib — a FUEL
FLUE SIZE RETURN OPEN GS 0 INPUT i, 01OUTPUT—64'
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warne Air Plants ❑Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑Hot Water into Required Side Yard Setbacks.
❑ echanical ❑Radiation Fireplaces with Box Additions or
Air Conditioning 2_1.-01N, ❑Special Devices Cantilevers to the Outside of Buildings
❑Vent. System DOther 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 $
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ /
This Application Becomes Your Building Permit When Approved Paid �iI lir
ipt No.
Building Official Datec bate/ 4
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372