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CITY OF PRIOR LAKE C/ Date Rec'd
01 c HEATING/AIR CONDITIONING/FIREPLACE PERMIT
jNIVEs��¢ .Pi"`` Fgt.,'
ile PERMIT NO
.Green city NO. I U--I I L �.
3.Yellow Applicant �l
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
s-1--,/,,s---/ ero ss&v.e,, ....... S V-
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNERn
(Name) mil i /C 1 4c-11 i (Phone)
(Address)
APPLICAN
(Name) P-1 D r 1.4.ke._ AN--e-A .--4 i C (Phone) 7 n
6 2—yk/ &l/O
(Address) /6SY59 7 PG-k)hk 4/-1,2) 61-- 1:3'`I',)r �--Kc MAJ..S- C-3?..)
(Address) (City) (Zip Code)
(Contact Person) A A (Phone)
APPLICANT SIGNATURE DATE _1_42_
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT 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 ❑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 4141 e_42,c-G1.1 54-..,,,,,..Q oa-..D
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 $ (A q 1 Su
STATE SURCHARGE $ S.''• -75ft
TOTAL PERMIT FEE $ S-, SJ
(Office Use Only)
This •,pplica . :e omes Your Building Permit When Approved Paid 0 _ (N Receipt No. p 1 2 3c,
�, U--)---)—(`' Date By b
Date l - 27-�� J�6
ildina Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372