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4. :' ,job HEATING/AIR CONDITIONING/FIREPLACE PERMIT 1.4. i s,
1.Pink File PERMIT NO15 '.
41.044 011' 2.Green City 7733.lellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
2-W i € c jkje , be kLt Ri
LEGAL DESCRIPTION(office use only)
LOT/9 BLOCK3 ADDITION Cvletiiin ', dri,o, PID oi 5. el 1/0-‘11/0-‘12,1/0-‘12,2Z —22
WNW7� �(NaOmeER) C L Q (Phone) . 2 — (81 - 2,11,5
(Address)
APPLICAN, ‘ - z--�'
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(Name) � � -fit r.. i _ � (Phone) -'
(Address) 2 It �. 1�k .1 . ,
(Contact Person) (\C (Phone)
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APPLICANT SIGNATURE . DATE 6 ,
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTIOI n, , PIr MEN ALTERATIONS
FURNACE MAKE AND MODEL I'1 -� FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE:Air Conditioner
❑Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity DHot Water into Required Side Yard Setbacks.
■ echanical D Radiation Fireplaces with Box Additions or
:! ;it Conditioning D Special Devices Cantilevers to the Outside of Buildings
D Vent. System ❑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 $
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid t•6-0 Receipt No .j, W
Building Official Date Date ,.,-. 1�- By yyt
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24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372