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N� CITY OF PRIOR LAKE Date Rec'd
x HEATING/AIR CONDITIONING/FIREPLACE PERMIT
44,,,,,..•.,>)
I. POce Cit PERMIT NO. //77
2. YCity ' L / /'1// /
3. Yellow Applicant (1 ( (�
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
c -7 I — l(O Tirt 4. — -5 c=
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID 4-S--- -lb( a I if r 6
OWNERi_ per_
(Name) D h t e fl bIC el 4 q.wi 50` (Phone) y.Sc. —1/ —6.513
(Address)_5-'53-7 1 — /too T �,y-- 5 e Pr t rest.-' L c.r � tf TO 4-,—,-,-;----3� . _
APPLICAN
(Name) ' vi i ' e'.- ......Y--vi (Phone) 9,502 —9 y/--/O 4'lf
(Address) 7 y0. - 1-(/4./.i j (7 r1z, v7 4-(a� i�=ci�i /ra �^: nAIS, '
(Address)/
A ss) ! , i (City) (Zip Code)
(Contact Person) --1 o Ii ii 4 1(_f+ (Phone)
APPLICANT SIGNATURE / % DATE /O a- 9—AO
APPLICANT PL 50E COMPLETE BELOW
ANEW CONSTRUCTION _OREPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL y ' i e.-y--
.." i-t-17x- IGCO'/.--G FUEL /U 9 fiCJ
FLUE SIZE 8y-Plilj RETURN OPENINGS INPUT /00,..GeV OUTPUT 9 5/227
TYPE OF SYSTEM HEATING OR POWER PLANT
IF Warm Air Plants 0 Steam PLEASE NOTE:
['Gravity 0 Hot Water Air Conditioner Units
Mechanical 0 Radiation Cannot Encroach into
DAir Conditioning 0 Special Devices Required Side Yard
[Went.System 0 Other Devices Setbacks
1 FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial,Commercial&Multi-Family 1%of job cost Residential,Gas Fireplace $39.50
$39.50 minimum
Residential,Heating&A/C(New Construction) $99.50 Residential,Additions&Alterations $39.50
Residential,Heating Only(New Construction) $64.50 Residential,AC Only $39.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ ".,)aj e SO
STATE SURCHARGE $ i
TOTAL PERMIT FEE $ ,,or s 7,3-1)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ,/ s, Receipt No.6 /
Date/1,
By
Building Official Date /t". L L i!
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
16200 Eagle Creek Avenue,Prior Lake,MN 55372