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v, pRIO CITY OF PRIOR LAKE Date Rec'd
i...fR104, CITY
HEATING/AIR CONDITIONING/FIREPLACE PERMIT c' Zjid
jNNEso 1.Fink File PERMIT NO. ��jj��//��
2.Yello City V N, o&56.
3.Yellow Applicant ii//
(Please type or print and sign at bottom)
ADDRESS I tif�j�0 C)G ((fa
IL of 13e
4 e.„4 4,..„ ZONING(office use)
...55
LEGAL DESCRIPTION(office use only)LOT BLOCK ADDITION /?L5 /2O PID Z5:7-437"-•0O LC
(Name) I 'VII 5Y1 (Phone) 12- V —70?O
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
(Co 1 - - '- •n / IIIIIIIIIIII/ (Phone)
APPLICANT SIG'4 ATURE J ��� DATE / Z 2"/c2 9
APPLIC= T PLEASE COMPLETE BELOW /
\ ❑NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE AND MODEL FUEL
FL RETURN OPENINGS INPUT OUTPUT
'E OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices
❑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 $ 4/, 50
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5-V,VI)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid(s---6 00 R ipt No.5-y/67 r /67
Date t/ P�j
Building Official Date D / .
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372