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CITY OF PRIOR LAKE Date Rec'd
t.,' A N e
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
4NN E s°�
.
2 1. PiGreenne Pile PERMIT NO. l 6"/ r-5/7A
(Please orprint and sign3.Yellow Applicant
type at bottom)
ADDRESS ZONING(office use)
Zoll `1 .0x Rwr) N\N �P 54
LEGAL DESCRIPTION(office use only)
LOT 14 BLOCK / ADDITION -- `^ (4 '644 PID z,j-Rg7'ti9 -o
(Name)OWNEv7613 �, _ L� (Phone) ("I S 2 4 0) Vo n) 0
(Address) 2-S11 Fp?‹ Z\A}(1 N V V
APPLICANT
(Name) \i'l
C ) l-min (Phone) ( (t2) 26S- -1 3
(Address) 2 V6 0" I ItAi\ii \ YV\ S V 1 u
I I-C � Z
�n ddress) (Citty)r ,, (Zip Code)
(Contact Person) (\IVA U 10 \ 1 01 WI (Phone) 1 lel(Z� 2 5 j-Sig 2)
APPLICANT SIGNATURE E iVA I DATE
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL CA,Y f Q sqfp(06 IRC 7-1 -7,0 FUEL
FLUE SIZE RETURN OPENINGS INPUT 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 into Required Side Yard Setbacks.
0 Mechanical 0 Radiation
❑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 $49.50
7.4AM
Estimated Cost$ 04iii. V Building Permit #
HEATING PERMIT FEE $ 401.66
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ 50 .6
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ,9-.---61
D ,c7) Receipt No. 33 57
Date / By
(35.„..
Building Official Date 7 i [c.„—.
5
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372