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o� r RIOT CITY OF PRIOR LAKE
�i L7'd HEATING/AIR CONDITIONING/FIREPLACE PERMIT Date Rec
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File L1h1T NO. //('�
ease or t and si at bottom 3.Yellow Applicant V i /f6 Z
ADDRESS /� v
L0054 `-�..J �1 -1d (l r . SP> ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNS r
(Name) .71i110,, di r
(Address) )
(Phone) - I 4.
APPLICANT
(Name ti _ft _ 1111 (er y _ �yy�
!•>..� (Phone) Z--Lb) -_____,_7__ ____
U-I`I
(Address) �� ..
(Address)� ' " � • M4R�� di ' A -.....-Ae I (City) (Zip ode)
(Contact Person) - ( > ,
(Phone) —����-t L �
IA
APPLICANT SIGNATURE
=---n�-- -4,..._,.. DATE HI ,t
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION 0 REPLACEMENT �TERATION
FURNACE MAKE AND MODEL 1.1.(1-- — Lt6—RL - La
FUEL rQ
FLUE SIZE
RETURN OPENINGS INPUT
TYPE OF SYSTEM �----_ OUTPUT EiczyCiCrTh
HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants 0 Steam
❑ avity 0 Hot Water Units and Fireplaces Cannot Encroach
I. ,ec anical
*7. ' onditioning ❑Radiation into Required Side Yard Setbacks.
W Vent.System 0 Special Devices Fireplaces with Box Additions or
0 Other Devices Cantilevers to the Outside of Buildings
FIAKE AND MODEL Require a Building Permit.
Industrial,Commercial&Multi-FamilY 1/a o FEE SCHEDULE
of job cost Residential,Gas Fireplace
Residential,Heating&A/C $49.50 minimum $49.50
(New Construction) $149.50
Residential,Heating Only(New Construction) $64.50 Residential,Residential,ACCdOnly AOnly &Alterations $49.50
$49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $_______44
STATE SURCHARGE $ .50
(Office Use Only) TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid ,
Receipt No..5-72./4__
Building Oficial Date/ 2/ '- By &MNDate
24 hour notice for all inspections(952)447-9850,fax(952) ' 7-4245 /
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372