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o� FR/04> CITY OF PRIOR LAKE Date Rec'd
Af e HEATING/AIR CONDITIONING/FIREPLACE PERMIT
1.Pink File
qINNEsolP 2.Green City PERMIT NO. /50680
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
alS1 CJLam. PI
LEGAL DESCRIPTION (office use only)
LOT '7 BLOCK 7 ADDITION p A4L ',4L ,1/ PID 075--300 -tSZ-O
OWNER / /) p
(Name) V_ A� 1C (4' Luca. C,� tJ A (Phone) (OR"S7U "3-D
(Address) (IS � c..v q+n U t" l Y l -ph() ,, l � on
I t
APPLICANT ,
(Name) U0( Mil \
(Phone) aJnr-�Q59�/- U�I
V
(Address) n\5\41. SheiZD
(Contact Person) q'
(Phone)
APPLICANT SIGNATURE IF p /U,/iA DATE ZAA.3
APPLICANT PLEASE COMPLETE BELOW
►:I EW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
VA,\
FURNACE MAKE AND MODEL f \Ci\'V , y� FUEL fl G1/J vat
FLUE SIZE RETURN OPENINGS INPUT mOto OUTPUT 1—,
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants D Steam Units and Fireplaces Cannot Encroach
•Gravity ❑Hot Water into Required Side Yard Setbacks.
echanical DRadiation Fireplaces with Box Additions or
J it Conditioning D Special Devices
❑Vent. System Cantilevers to the Outside of Buildings
Y D Other Devices Require a Building Permit.
FIRE-PLACE-MAKE AND MODEL' \�r� '%1\\ .2.1(\ 034,
r\� 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 i�Prr
e7miit#
HEATING PERMIT FEE $ bl�•`a
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 5
This Application Becomes Your Building Permit When Approved vi t Receipt No.
s 67
Building Official Date Date Up, +\n` l� By
24 hour notice for all inspections(952)447-9850_\
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372