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rRlo CITY OF PRIOR LAKE Date Rec'd
N �e HEATING/AIR CONDITIONING/FIREPLACE PERMIT 7 / ,,p
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4fjNNESD�A 1.Pink File 0 9, 05-240,
2.Green City
PERMIT NO.
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
563a L 0 fill.« 2oac)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER ----.1 --.-
(Name) A rvc.S 1 c ( C 4-1'0 (Phone) q 5 Z- 114 0 - 731 V
(Address) 5 6 3 () L.31-1,-,c-C 2O c J
APPLICANT
(Name) 1L..e._g I3 t,-*-o.\ \-\e-C.-A ,- A ,r (Phone) 61 Z- 1 z9-t g qui
(Address) A'615 Q- ' ' 51- SO }c A iN'1.r1r,cc, 1,S - M., 55407
(Address (City) (Zip Code)
(Contact Person) _A-r -.` o \"'NV (Phone) 6(2..- 7 Z 4-t S ci^1
APPLICANT SIGNATUREDATE
!.
AP LICANT LEASE OMPLETE BELOW
❑NEW CONSTRUCTION [PLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL C& rr.cc 5 6 r-,v co BC) c15 1v FUEL N ck i- 6 a
FLUE SIZE RETURN OPENINGS INPUT 8 U,0 c' OUTPUT 7 6 r OCv
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
DVent.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 $49.50
Estimated Cost$ 5 0 0 0 O() Building Permit #
HEATING PERMIT FEE $ L44 `S a
STATE SURCHARGE $ .50
. TOTAL PERMIT FEE $ 50 as
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Sp60
ceipt No.51!)449
Dates/ /„ o
Buitdfn¢Official Date / ` 111
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372