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—1r Q
rR10 CITY OF PRIOR LAKE Date Rec'd
M HEATING/AIR CONDITIONING/FIREPLACE PERMIT 9: /7. /4-
U trf
1.Pink File PERMIT NO.
`/1NNESOfP 2.Green City 4(0 6
3.Yellow Applicant
(Please,type or print and sign at bottom)
I•! - ZONING(office use)
3873 O'Bit•cn CTSw, Pato ' Lakc
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
t WN R .-51 al-1y/ C)ru.
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Contact Person) (Phone)
%_,_4:PPLIdANT SIG
,E 9-/ 7 -P-/
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑REPLACEMEb. •ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS IN)UT OUTPUT
TYPE OF SYSTEM HEATING OR 'OWER PL� PLE SE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam k Uni and Fireplaces Cannot Encroach
❑Gravity 0 Wa r (
/O ,�'( /l/17" in � Required Side Yard Setbacks.
❑Mechanical EiRadiati )n 1D fi 'Emplaces with Box Additions or
El Air Conditioning Special'P evices P Cantilevers to the Outside of Buildings
❑Vent. System 0 Other D- ices 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 $ 49-s15
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 54
This Application Becomes Your Building Permit When Approved Paid3 r0 /RecNo. 77,..z.Building Official Date Dater /7 t
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372