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Dov VRrp�� CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT --
tr
411NNEsW` 1.Pink File PERMIT NO.
2.Green City /
(Please 3.Yellow Applicant ��—C�
type or print and sign at bottom)
ADDRESS \
13
g00 `C ZONING(office use)
UYNNY\ Wal_N 12--i
LEGAL DESCRIPTION(office use on y)
LOT BLOCK ADDITION PID •0-rd.cot.
OWNER ��/
(Name) CA a V\ (up\p c yy) \ (Phone
(Address) i ) C --AAD Y\VM ,Y' CX 4 . c \e ✓ (._ c,\,_ IL
APPLICA A C
(Name) \ Y\V\ 1s606`FCWiln,I�)1 Vl r e 9,C "hone q — —
(Address) 1 y o�d �� ,� G • Q__, a v V \�
s
3
(Contact Person) L k\A t�.Ss2L7C- IA (Phone) 9 5 2 q qn-(41-1)W
APPLICANT SIGNATURE ...---i4-2( DATE S`-72-7S—
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION 0LREPLACEMENT " 0
FURNACE MAKE AND MODEL ALTERATIONS
-�+2VVN0 x L q�CV 1 o FUEL C....--
FLUEFLUE SIZE RETURN OPENINGS INPUT
T 1l6,60r) + 614 OUTPUTjocasu 1-
rilwekb
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants la.�� PLEASE NOTE:Air Conditioner
El Gravi 0 Steam Units and Fireplaces Cannot Encroach
�' c.K.4'r 0 Hot Water into Required Side Yard Setbacks.
E.Mechanicalq
0Radiation Fireplaces with Box Additions or
'FiAir Conditioning 0 Special Devices
Cantilevers to the Outside of Buildings
❑Vent. System ❑Other Devices
FIREPLACE MAKE AND MODEL Require a Building Permit.
FEE SCHEDULE
Industrial, Commercial&Multi Family 1%of job cost Residential,Gas Fireplace $49.50
Residential,Heating&A/C $49.50 minimum
(New Construction) $149.50 Residential,Additions&Alterations $49.50
Residential,Heating Only(New Construction) $64.50 Residential,AC Only $49.50
Cost$ (Iii b 01 Building Permit#
HEATING PERMIT FEE $ 4c7,-5-6)
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ Sl-t.S 0
This Application Becomes Your Building Permit When Approved Paid 94,,,s---0
Receipt Nol zk3
Building Official Date Date s . 12, 15— By gatkt moi
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372