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CITY OF PRIOR LAKE Date Rec'd
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HEATING/AIR CONDITIONING/FIREPLACE PERMIT _
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Pink 2.� c File
PERMIT NO./5 /c-//o
3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS V9V,, -'�j� -6/7d/i- ,<'/-- /-77iGr" &(-,e_ . 711/7 -- 72- ZONING(office use)
P1
LEGAL DESCRIPTION(office use only)
LOT 7 BLOCK Z ADDITION / (Tay / j'A_>CY 4.) PID 075—OV—' 7. 74 -40
OWNER '���/
(Name) .-- C4/--- C / /",--/70r-C/7 (Phone) '9V-.;2- /-- /S--
(Address) /.7-s--//l�✓�/%7Ci,/e• s-/- /&/'&O/ ,,(-fie ~ S�J7 --
APPLI
(Name)CANT/ 7/4L7 g/7)--7'‘')1"74-. (Phone) -7(e_ % J/ .86 -9 .
(Address) /1///7/7-7%ZC 74 /l%D/. / /-1.,e - MA <%W 7
(Address) ( ity) (Zip Code)
(Contact Person) _ , yLrb /w s (Phone) 7(/ 5i9. g c/V
APPLICANT SIGNA �/ / DATE /c / /c9 /J
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APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION M&EPL/JACEMENT ElALTERATIONS] ��r
FURNACE MAKE AND MODEL 6e/7/7a (_07z, //172 7/, FUEL /rya'
(/(i7
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 0 Hot Water into Required Side Yard Setbacks.
ELMechanical 0 Radiation
❑Air Conditioning 0 Special Devices Fireplaces with Box Additions or
OVent.System 0 Other Devices -�I,U—i2ae-e% Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial,Commercial&Multi-Family 1%ofjob 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 $49.50
Estimated Cost$ j AP - Building Permit #
HEATING PERMIT FEE $ �� S-0 1,1
v�
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ dD.57)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5.-0, -.0 Receipt No. bi 5 v
Building Official Date Date l 1 g_ 1c By 1 L I vi i X!
24 hour notice for all inspections(952)447-9850 �^
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 / . VI ki-d9115 kti