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4P RIp� CITY OF PRIOR LAKE Date Rec'd
Ef eHEATING/AIR CONDITIONING/FIREPLACE PERMIT
7.13/ /,3
`ItJ�IVEso ', 1. Pink File
2.Green city PERMIT NO./5' 003
3.Yellow Applicant b
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
'furl(o 13-12A1A 611/500 (?L%J) NE 816,D
LEGAL DESCRIPTION(office use only) /� >> J
LOT g BLOCK 1 ADDITION C!►f+°/ /4 Lis 2-Nb PID 0?5- Z -oO tet)
(Name)OWNE --r}-�� 1 I M S (Phone) 416.2..440 .P(AO
(Address) S► } �-4\
APPLICANT Appliance C( inections Inc.
(Name) 12850 Ci �thmit Blvd. (Phone)
(Address) Shakopee, MN 55379
q (Address) �J 952-445-4803 (City) (Zip Code)
(Contact Person) �'► 1i (- F -; (Phone)
APPLICANT SIGNATURE y DATE 14-1--S-
APPLICANT
PL"ASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants ❑Steam PLEASE NOTE: Air Conditioner
❑Gravity ❑Hot Water Units and Fireplaces Cannot Encroach
Mechanical ❑Radiation into Required Side Yard Setbacks.
it Conditioning 0 Special Devices Fireplaces with Box Additions or
E)44:
ent.System 0 Other Devices Cantilevers to the Outside of Buildings
c-- Require a Building Permit.
WRIEPLIceE MAKE AND MODEL p l33's to i N
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 oritteritig,AC Only $49.
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ LEI.50 --
STATE SURCHARGE $ 5.7. Ob vszc
TOTAL PERMIT FEE $ 61490
(Office Use Only)
0
This Application Becomes Your Building Permit When Approved /I1Y ►aid`3 ,‘••• Receipt No. (91 la\
l
.D
Date_ Y\ . \� By
zo 7
Buildin¢Official Date e
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372