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01 PR10
'.? CITY OF PRIOR LAKE Date Rec'd/1\,.
rq HEATING/AIR CONDITIONING/FIREPLACE PERMIT
l y /D. 211�'NES
I.
File
PERMIT NO.
3.Yellow Applicant O 09
(Please type orprint and sign at bottom)
ADDRESS ZONING(office use)
IS c0 SIcy /A Ave_ 41W
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER J L l Q
(Name) W f e (\d4cA`A. (Phone) l 1)-- Ertl
(Address) I %'''''75
�\ ! G J L.-., e' 11x..
APPLICANT / G / f l
(Name) Cy/Cr lira'Ti/+") j-4/-- -i-A c . (Phone) l2 I t N� 6 (4)--,2
(Address) ,Y)3 l // i/te" ( i 5- mj S 7 d d
(Address) (City) / 1 , (Zip Code)
(Contact Person) 3ite-A-t (Phone) G d`-7 `�1- Ge;-.2.
iii
APPLICANT SIGNATURE DATE /0"4)-o — 0 /
will _
APPLICANT PLEASE COMPLETE BE OW
DNEW CONSTRUCTION 1 0 / O{
REPLACEMENT ALTERATIONS c
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
OWarm Air Plants ❑Steam PLEASE NOTE: Air Conditioner
Units and Fire laces Cannot Encroach
['Gravity 0 Hot Water p
into Required Side Yard Setbacks.
Mechanical
0 Radiation Fireplaces with Box Additions or
['Vent.System ❑Special Devices Cantilevers to the Outside of Buildings
❑Other Devices
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) $64.50 Residential,AC Only I
Estimated Cost$ I $ ' Building Permit #
HEATING PERMIT FEE $ Lici.S v
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ Q1-cit)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.Jj—y0s4_
Date
Building Official Date
/0,04 v
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372