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� CITY OIF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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(Please type or print and sign at bottom) 3. Yellow Applicant
ADDRESS —
I2-IC)1 �I�l'J� —S �(I� NE ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER - II �, l
(Name) 1C1(l�i�l °D�L1�1•1 MSCh-O (Phone) (0I2• W$"2092.
(Address) I57 i---"�i{IYbrAO-c--;-\--I 1t) J k Cio- -12
APPLICANT-i— A1(Name) ! �\ (t)} a$ (Phone)
(Address) '1.00C u V\)nd / Ak KJ 4MC l N Htpe, YW J2( ddress) / (City)
(Contact Person) C1VA ,i)Y1 C\'(.,� (Phone) 10
APPLICANT SIGNATURE-All 1
DATE
APPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION REPLACEMENT El ALTERATIONS
FURNACE MAKE AND MODEL 1j'�e T-1/4-\� 0,046\1 FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
OWarm Air Plants 0 Steam
OGravity ❑Hot Water Units and Fireplaces Cannot Encroach
Mechanical ❑Radiation into Required Side Yard Setbacks.
Fire
Air Conditioning 1
:Went.System ❑Special Devices p aces with Box Additions or
❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
Industrial,Commercial&MultiFamil y 1%of jobFEE SCHEDULE
cost Residential,Gas Fireplace $49.50
$49.50 minimum
Residential,Heating&A/C(New Construction) $149.50 Residential,Additions&Alterations
Residential,Heating Only(New Construction) $64.50 $49.50
Residential,AC Only $49.50
Estimated Cost$ 15 Building Permit #
HEATING PERMIT FEE $
STATE SURCHARGE $ 1.00
(Office Use Only) TOTAL PERMIT FEE $ .0
This Application Becomes Your Building Permit When Approved Paid
Recei No. a,cfc
Building Official Date Q� J'— By
Date c7
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372