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R CITY OF PRIOR LAKE � �� ' �� ``� �"ba�te R� � �
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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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� ,. P "� F `�` PERMIT NO. �Z �� �i,
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3. Yellow Applicant
lease or 'nt and si at bottom
ADDRESS � � ZONING �at��,��
W I v
LEGAL DESCRIFTION (office use only)
LOT BLOCK ADDITION PID
(N ) � (Phone) "l�c�Z' 1"�( � I �'n
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(Address) �'i' Z 7, � (SJ Y � T"
APPLIC T � ��� f A � � r , ( 2 � _ � � /� �
(Name) � V �.t/(Phone) l�,l� '-� J /
(Address) �� V ` 4� d 7 �
(Address) (City) (Zi Code
(Contact Person) (Phone) ��� � �� ^ �� ` �`'
APPLICANT SIGNATURE DATE �
APP ANT PL SE COMPLETE BELOW
�NEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL q(,� �� V1 �� g FUEL r\�� C.�Q(�
FLUE SIZE RETURN OPENINGS INPUT� (�, (�O � OUTPUT � O��
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
� Gravity ❑ Hot Water into Required Side Yard Setbacks.
Mechanical ❑ Radiation
Air Conditioning ❑ Special Devices FireplaCes with Boz Additions or
❑Vent. System ❑ 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 $ 'f t• S�
STATE SURCHARGE $ -�i . 0 '�59
TOTAL PERMIT FEE $ c,�-} ,,�s��
(Oftice Use Only) `�
This Application Becomes Your Building Permit When Approved Paid r�� Receipt No. 7` `.�
`.� �43
B�ua��Qotr��ai nete Date fl / B
Y �
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372