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PRjO(S.
/ CITY OF PRIOR LAKE Date Rec'd
\ HEATING/AIR CONDITIONING/FIREPLACE PERMIT
`1tlNNESO�
l PGre rile PERMIT NO.��- ��Gj
I Green City 7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
550 � bbl-evooed, E
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID 96Q /5D730
OWNER A
(Name) ( �.Yl(� M c y 15 O(Th (Phone) 95 a-(-{!.i 5-- (p' g
(Address) 5Sa3 Ambl-e-wt�c t Jef P6 or LoJCe fMN Ss317 a
APPLICANT (t ,,�!
C _ A
(Name) Co � r (Phone) 1051'i-41.20 l Q D -
(Address) at -1C) Ems- A n ue cur Nu IrkcitOY> Mn) SSO aL
(Address) City) (Zip Code)
(Contact Person) ea (Phone) (p5)—Li t.QO Lac a�-
APPLICANT SIGNATURE .® DATE r7 —/ 6
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
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑Hot Water
❑Mechanical Radiation into Required Side Yard Setbacks.
SlAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System ❑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 $ 50
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid5- R eipt Noz,,f,„ery.
Date r
Building Official Date �S
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372