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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
U tori
�P 1.Pink File PERMIT NO.
t
NNESo 2.Green City `5 3 f3
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
SS"7 6 '4vb\-e
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNERA
(Name) OS\f\ Qom« (Phone) ) ate^ 0S-41
(Address) �S ?(c, '�n,*b�W oOCk ,J r
APPLICANT
(Name) ,SSE / /9-15.01 (Phone)
(Address)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
W CONSTRUCTION 'RREPLACEMENT 0 ALTERATIONS
FURNACE AKE AND MODEL FUEL
FLUE RETURN OPENINGS INPUT OUTPUT
YSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
0 Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning ❑Special Devices Cantilevers to the Outside of Buildings
❑Vent. System 0 Other 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 $ 7.
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 57 s-�
This Application Becomes Your Building Permit When Approved Paid 32/573 Rec +t No./do.5
Building Official Date Date�. 43-/S B
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372