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�.�Q4 PCITY OF PRIOR LAKE Date Rec'd
1 HEATING/AIR CONDITIONING/FIREPLACE PERMIT
NNE SOS
q11 = ��
1.Pink File S a l c/
z.Green Cay PERMIT NO.%
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
� I �" Crcte
ZONING(office use)L �\� NU) /2i5))
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID c95- 37 1-(TAP 0
OWNER J
(NaOhf S 0 fl (Phone) `'li- zzo-z i-1 s
(Address) 3221 1 u C`rc\e_ ND
APPLICANTA- 1 i
V
(Name) fAl t-re y,I 1 L-L- (Phone) cf5Z- L 5-- 0032-
(Address) Z �-�� is Sliot.msv\\l p 553-51
_ (Address) (City)
(Zip Code)
(Contact Person) OV‘ia\n t � n
(Phone) �Sl � z — Z � � < < 3
APPLICANT SIGNATURE TCWjik.)LL x, SAT /Z 1 5
APPLICANT PLEASE COMPLETE BELOW
:NEW CONSTRUCTION REPLACEMENT 0 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
0Gravit ❑Hot Water Units and Fireplaces Cannot Encroach
into Required Side Yard Setbacks.
❑Mechanical 0 Radiation
Air Conditioning RUU D 0 Special Devices Fireplaces with Box Additions or
Vent.System RA13`{2AJ1 M A 0 Other Devices Cantilevers to the Outside of Buildings
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 $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ L+ .S-C)
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ 7) .S7-7
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid `TT..? Receipt No.
Building Official Date Date r 1 By s '-y.
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372