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V
ov.PR/0, CITY OF PRIOR LAKE Date Rec'd
4, `' HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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jNiYEsoo
1.Pink File
2.Pink City PERMIT NO. C 9 eel
(Please type or print and sign at bottom) 3.Yellow Applfel i
ADDRESS &t U
lU r I'/� Cox4-
ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
I��� � PID
(Name)R����v y`_' n ) I (Phone) !Sa WO 83
25
(Address) ) (...9( 01) W. (,,.1 n `
- 9"rLLY' �� �11.--
APPLICANT ' N P1UMbW9(Name) �'I 11PP4yh19 )I J � (Phone(Address) I� W. �� S'lAo
(Address) (City)
(Zip Co
de)(Contact Person)PAakSi/II Wold
- (Phone)%S� 9-91/Li
APPLICANT SIGNATURE Iitl1/4.; / DATE
//- e s---0
APPLICANT PLEASE COMPLETE BELOW
ANEW CONSTRUCTION REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL(t,o4M64l GGYY1 ).q s-bi 15gx. FUEL Co-60
FLUE SIZE RETURN OPENINGS INPUT
OUTPUT
TYPE OF SYSTEM HEATING.OR POVVER PLANT
(«Warm Air PlantsPLEASE NOTE: Air Conditioner
❑Gravi ❑Steam
�' ❑Hot Water Units and Fireplaces Cannot Encroach
into Required Side Yard Setbacks.
Q Mechanical
QAir Conditioning Q Radiation pFire 1
❑Special Devices aces with Box Additions or
QVent.System 0 Other Devices Cantilevers to the Outside of Buildings
FIREPLACE MAKE AND MODEL Require a Building Permit.
Industrial,Commercial& o FEE SCHEDULE
Multi-Family 1%of job cost Residential,Gas Fireplace $49.50
$49.50 minimum
Residential,Heating&A/C(New Construction
Residential,Heating Only Construction) $149.50 Residential,Additions&Alterations $49.50
(New Construction) $64.50 Residential,AC Only
$49.50
Estimated Cost$ c O v Building Permit # 9. 9 Pi
HEATING PERMIT FEE $ 4/9.
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ e5 -cr-c)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid
I/4 /2
?/9 Receipt No.s,v 5.0
—__.-r— / `S/�7 s 1 Date f//2.5A/__ By
Buildine Official Date _ ...../c
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372