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1 PR/O4, CITY OF PRIOR LAKE Date Rec'd
z HEATING/AIR CONDITIONING/FIREPLACE PERMIT (Q . /3 /3
..,
U tr1
�, 1.Pink File PERMIT NO.
INNEso� 2.Green City ( �
3.Yellow Applicant -goes
(Please type or print and sign at bottom)
ADDRESS G j 57 A)Oab e, .yt S/(PPZY ZONING(office use)
5"3 7 O fit,)IS ?e00OO Ort v& S"E.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PIDZS: q3(0 . 601, 0
(ONam)R ic-.i # 7/9 (Jèi De Ct Guidi (Phone) 96•2- Z Z 4 od 5,
(Address) 4'$VO 734tide, STiaC7 5-E.
APPLICANTp' ,/
(Name) 5.0 2/9 (Phone) ! 5-2-Z Zoo-CIO 5
(Address) '(5' 'O 7D4o :ic 5D C7 Se
(Contact Person) 37.1/ iaPi GJ 1) (Phone) 963z- ZZ6 66 5,1
APPLICANT SIGNATUIC DATE 411/413
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 SteamTUnits and Fireplaces Cannot Encroach
❑Gravity LtiY�ot Water into Required Side Yard Setbacks.
❑Mechanical ❑Radiation Fireplaces with Box Additions or
❑Air Conditioning ❑Special Devices Cantilevers to the Outside of Buildings
Went. 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 QQ Residential,AC Only $49.50
Cost$ .zz.8 6?z o Building Permit#
HEATING PERMIT FEE $ 02i7, Z./Vs
STATE SURCHARGE $ 5.0046 0TOTAL PERMIT FEE $ a�Qa.., z,r 4
This Applica//'i nik ecomes Your Building Permit hen > a proved Paid ZZ9 Z:at/ Receipt No.6 936¢
Bu' ding 9:1741,1.1.10p Date > 2,4, ./3 By
Dat
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372