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PRro�� CITY OF PRIOR LAKE Date Rec'd
r ,� ) HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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I. G k File PERMIT NO. /5-/i//5-
3. Yellow Applicant 7
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
4 323 Proyood i-. .5..E 8 Z
LEGAnL DESCRIPTION(office use only)
L(7T" i LOCK q Z ADDITION e.eA 1/r /-44�s 0/6 4/03
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PID 2-5-- 3a3q_�9' -0
OWNER
(Name) LIM- �14/ //�� w
l (Phone) "IrbZ• 441- 5104v
(Address) 4523 Pirt rWood' S. 5E.. , -Oriw
APPLICAN "�,, " 1,, I'
(Name) .W�1/Li 01 Y0. t 1W D) (Phone) ilk 1413- 121/7
(Address) I t 31 1Aka IIA..& , Pi 1,w o , �YV► 55 447
(Address) (City) (Zip Code)
(Contact Person) Q1uh J (Phone) 11/3- 1 '-j k'
APPLICANT SIGNATURE A//14,v( DA 1'E 1I-1(p 2IJIc ,
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION �1['REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL b AN MOti 'Wit
it FUEL I v G
FLUE SIZE RETURN OPENINGS INPUT
W1 DDD OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
[Warm Air Plants PLEASE NOTE: Air Conditioner
❑Gravit ❑Steam Units and Fireplaces Cannot Encroach
Y ❑Hot Water
into Required Side Yard Setbacks.
0 Mechanical 0 Radiation
[ r Conditioning 0 Special Devices Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
❑Vent.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 $49.50
Estimated Cost$ 1IO02.-00 Building Permit #
HEATING PERMIT FEE $ 40i 50
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ t).(51)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid/ b�11 lJ� Receipt Not�Date` By
Building Official Date l'
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S•E.,Prior Lake,Minnesota 55372