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CITY OF PRIOR LAKE Date Recd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
• *NE 5
1. Pink File
2.Green cm PERMIT NO. / j)/7 /nt3. Yellow Applica
(Please type or print and sign at bottom)
ADDRESS , �;� � n ^ � ZONING(office use)
?13 1U A1)6
LEGAL DESCRIPTION(office use only) L� jC / ._
LOT 3 BLOCK `ADDITION 5��-�Y Zzir;-
OM e//ls'1 hi(46 a.5--30-7'" ,..5- "-0
OWNER
(Name) �U"v �' (Phone)952--fit-{,— �J 3 ?s'--
(Address)
Sr(Address) 28 23 (-0-06c. IN\ `v
(Name)) ) r) C`,`5 1-1 C�v�,i 1 fl L.-LC (Phone) Q5� ` 3LI5_)032-
(Address) 2-Lt) 00 \Al {- \A!\/ 1.3- 8u m svi , ,e 56 331
(Address) (City) (Zip Code)
(Contact Person) 'CA W�jn i , , ,.... A (Phone) t I Z— Z 55—5' 1 q _
APPLICANT SIGNATURE I ATE 411/30/l ( 5
• cr-23
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION REPLACEMENT 0 ALTERATIONS
-FURNACE MAKE AND MODEL e)I- I s304-J I YU 13 FUEL
•
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
DWarm Air PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
mechanical ARadiationinto Required Side Yard Setbacks.
AirConditioning Special Devices Fireplaces with Box Additions or
:Went.System 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 $49.50
Estimated Cost$ AWb•00 Building Permit #
HEATING PERMIT FEE $ Lf`9- SI)
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ 5o.51)
Illrfficc Use Only) / �0
This Application Becomes Your Building Permit When Approved Paid �j Receipt Na,
Dat ,.. � �y / By
Building Official Date (,/ �„�( is_
'1
24 hour notice for all inspections(952)447-9850_ v l ›),.....______....---:
(((JJJ
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372