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s,4 P R`()4, CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT Date Recd
a . 17,4. �x
U �
M,n'NE s or. /
1.Fmk File
2.Greenllow Arplaplioant 7 PERMIT NO. Q%f 0Q5g
(Please type or print and sign at bottom) s.Ye
ADDRESS
15 q30 eprecz y point- Pct. SE. ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNER
(Name) II I. .11111 . IIC.. (Phone C'44 I�y
- 515g
(Address)V 54 3,3 brecZ\/ To 1 rir 1"la, SE
APPLICANT C. . aa
(Name) f• AIM,M - . _ (Phone). - • ( )`'I5-�—`.''13ry1— 71yq
(Address)(A 30 L.3. 14c ' + t3 . • IPJ vat. i 53 ,a4
(Address) �1
(City) J (Zip Code)
(Contact Person
(Phone) q --431 i oge
APPLICANT SIGNATU
4 DATEZ7CI
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION [REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODELC
FUEL
FLUE SIZE 1r �
RETURN OPENINGS
INPUT 60�(`�(_ o OUTPUT
TYPE 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
it Conditioning
0 Special Devices Fireplaces with Box Additions or
Vent.System ❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
ffREPt-AreE MAKE AND MODEIrtar(1 er"c IQ a -f t"l - a,- 4 .p Ta
FEE SCHEDULE
Industrial,Commercial&Multi-Famil1%
of job cost Residential,Gas Fireplace
$39.50 minimum $39.50
Residential,Heating&A/C(New Construction) $99.50
Onl Residential,Additions&Alterations
Residential,Heating y(New Construction) $64.50 Residential,AC Only
$39.50
Estimated Cost$ q 1 5 I ,9° Building Permit #
HEATING PERMIT FEE $ 4q. -�
STATE SURCHARGE $ .50
(Office Use Only) TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid
Rec, ,, No.3.7z4
Building Official Date V B
Date 2, (f,24 hour notice for all inspections(952)447-9850,fax(952)447-4 45
16200 Eagle Creek Avenue,Prior Lake,MN 55372