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4;) rRro� CITY OF PRIOR LAKE Cl Date Rec'd
AO" HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Z'') lx
'jNNEso`�A 1.Pink File PERMIT NO. f0 /0
2.Green City f 9
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
38 93 aSp6 — €JS- _ Pd ,ut
LEGAL DESCRIPTION
(office use only)
LOT BLOCK ADDITION Pu)
OWNER e.''` _/
(Name) J Tf vG✓l ? (Phone) 61 Z Vb -7 2:17
(Address) 3 b' , ee_v IC iq1 f e Nw ?ro lc t A/J �f 7 Z.
APPLICANT v
(Name) S- G k PK-s----- (Phone)
(Address) S✓17-1- E
(Address) (City) (Zip Code)
(Contact Person) / (Phone)
APPLICANT SIGNATURE A� DATE
' ' CANT PLEASE COMPLETE BELOW
❑NEW C• RUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Wane Air PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
❑Mechanical ❑Radiation into Required Side Yard Setbacks.
Air ConditioningFireplaces with Box Additions or
❑ 0 Special Devices
[Went.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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5'c{.cd
(Office Use O. y)
This . up ' a;/ B; om Your Building Permit When Approved Paid Receipx e.
w..4. // 2W Date By
V Building Mein-7Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372