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4 ?RioCITY OF PRIOR LAKE Date Rec'd
i.1,,, AN F
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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
�tN$50
I.Pink File PERMIT NO./5�Q
2. Green City
3. Yellow Applicant
(Please type or print and sign at bottom) ZONING(offxx use)
ADDRESS
Y4 Lk I \o114A,Q,ev,) Tcz_0;\` 5 c P (3cz- J M(`) CS-3-0--
LEGAL DESCRIPTION(office use only) f G
LOTS BLOCK ADDITION //2Q 7 & �� irJ PID 26-- 3360/b 0
OWNER
(Name)
LI 12—3 Z�S
(Name) (\\( ) o t'-`^ (Phone) 15
(Address) k(Lt t 1 l Po n cLv ie,vv l 9--c,:k. SC p R-,(Z. La (A..Z) M N S S 3 7
APPLICANT(Name) "Mt-c\\ Co k.^v-\.C (Phone) `7 6 3-39,3-c6 3r,3
� n t
(Address) ()GO W `h`("1-e (Address)A yr t , *4_ (00 . i i-Aor '-'(City) (Zip eo`ae) 7
(Contact Person) Tc-7--k(..1\'"\ C-7 (? CX 1 (Phone)
APPLICANT SIGNATURE tfi ,1.0 Si, . , _ ALI 1 ' DATE q/A-\5
i
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL 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 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
OVent.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 $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ 44•9X1)
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ �•uu
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 1/) cr) Receipt No. b I
Date I (By 5 .72r,
'Milldam Official Date q .74 c `J