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CITY OF PRIOR LAKE Date Rec'd
•HEATING/AIR CONDITIONING/FIREPLACE PERMIT �,
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2Green City PERMIT NO. / / J T'/3//J7
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a 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use) _
h\11 00006.0 AlA2 }J & 553-7 '
LEGAL DESCRIPTION(office u e only)
LOT BLOC ADD ION PID 2 4 ...„ ....,0
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(Name)OWNE ,` 1A „ Wi tc co (Phone) 95 445 4453
(Address) L; (JAC_„
APPLICANT
(Name) Appliance ConnetIi )Inc.
(Address) 12850 Chestnut Blvd.
(Addres . Shakopee, MN 553N-city) (Zip Code)
(Contact Person) a '1l 4 r / ..t / . 952445-48(P one) c
APPLICANT SIGNATURE Ihrii ��../ / ' , DATE V ) a.�
A'PLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTIONREPLACEMENT El ALTERATIONS
FURNACE MAKE AND MODEL 1Z 95 P R 04 130 7 Eo o(_% 1 FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑Steam Units and Fireplaces Cannot Encroach
OGravity ❑Hot Water
ID Mechanical l=1 Radiation into Required Side Yard Setbacks.
DAir Conditioning ❑Special Devices Fireplaces with Box Additions or
❑Vent.System El 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 $ I"\ 3°
STATE SURCHARGE $ _ 1.00
TOTAL PERMIT FEE $ �j()r,.b 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid✓v 50
Receipt No`6 2,).„'
i B �y
Building Official Date Date . 7)))7))) ,� i
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372