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4,/N, CITY OF PRIOR LAKE Date Rec'd
U
HEATING /AIR CONDITIONING/FIREPLACE PERMIT
d1j , SQ '
*iv ES°
2 Pin en Ciry File PERMIT NO. / / , ii 97
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office
5 � (
) /) C--) 0 k1C c /2 5i use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWN )R "" L 1 h D' � � (Phone) 1 -7 7 _ ( 2 -.),./
(Address) - 9,5 ( ) kV ^J c k C P 5(.
APPLICANT L ( — -- 1L (- —L973— 33�
(Name) f P 5 1 - DC 0 , H (Phone) U�
(Address) 7 00 t ^ A t.11 tJ 1 LX A.1 i a P 35 . v k t-,LE N . I ,3
(Address) (City) (Zip Code)
(Contact Person) D C l 4 IN At 1 (Phone) (O —(1 3 0 33°5
APPLICANT SIGNATURE .�"1/® _ DATE b l
APPL AN ' LEAS OMPLETE BELOW
['NEW CONSTRUCTION ❑ REPLACEMENT [1ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE:
❑W Air Plants ❑ Steam
❑Gravity ❑ Hot Water Air Conditioner Units
❑ Mechanical ❑ Radiation Cannot Encroach into
❑Air Conditioning ❑ Special Devices Required Side Yard
❑Vent. System ❑ Other Devices Setbacks
FIREPLACE MAKE AND MODEL JVAI 5,j76 - 3 3 ) 3 Z - - 1 '
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 Per it #
HEATING PERMIT FEE $ Kam'► ro
STATE SURCHARGE $ •5
TOTAL PERMIT FEE $ 9 1 a
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 6 - 1 _1 c � Recei o. �( 0 Z
Date 1 ( H By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245