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Rlo� CITY OF PRIOR LAKE ZDate Rec'd
e, HEATING/AIR CONDITIONING/FIREPLACE PERMIT
v g
\jNNEsd1.Pirenken CitFiley PERMIT NO.
2.Y
--- )4369
3.Yellow Applicant /�
(Please type or print and sign at bottom)
ADDRESS d ZONING(office use)
\ c
9\4i4\. W (L
LEGAL DESCRIPTION(office use only)
LOTq BLOCK / ADDITION t' /J Alahcgfaegl)kkPID Z5 OgV-odct /
OWNER f S.1 %i—I S / c
(Name) v � Q CA0-0 e,,Q1 r, A., (Phone)
(Address) \\\ c \ c 0\ -4ei) Q
(Name)APPLICST\J ' ____.\—Y- k., (Phone) \ . - D`��� -‘?,1 14
2� d frr Qc\,a . 1 S ^-
(Address) �� �� L 6� �G► � S � 1'�..
A� (Address) (City) `, Zip Code)j
(Contact Person) 'V0,\...1 (Phone) \ c a-.�`q/ -,g\ a�'1
APPLICANT SIGNATU DATE 114 \`1 44-A-C-
APPLICANT PLEASE COMPLETE BELOW j
❑NEW CONSTRUCTION _REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL%.--), (...0,--k- Th i s Po v v� �<N 9 C� FUEL N
FLUE SIZE RETURN OPENINGS INPUT q� )w OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
❑Mechanical 0 Radiation into Required Side Yard Setbacks.
❑Air Conditioning 0 Special Devices Fireplaces with Box Additions or
['Vent.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 $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ C\S7
STATE SURCHARGE $ V0
TOTAL PERMIT FEE $ S O r./?
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 50cl)1 Receipt Noy% 9.s.---'Date//. 1g . /
ate / y �J
Building Official Date r1. lQ . J S
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372