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; o � P,RIO, CITY OF PRIOR LAKE Date Rec'd
� � 9 HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� � :��;: x
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'� � !. Pink Filt
! 2. Green City PERMIT NO . !
' �. Yello�v A Lcant ��' /� �
(Please ty e or rint and si n at bottom vv'
ADDRESS
! ( �^� �� ZO1�TIl�TG (uff'ice use)
J �
LEGAL DESCRIPTIQN (oEtice use only)
LOT BLOCK ADDTTION P �
OWNER I_ � - —
(Name) _ U\ I I I V v\ I v��,�, (Phone) � � 2 �
� (Address) a � J ~ '
C ri Y�
APPLIC T , ,]�,
(Name) \ � � � Itl\ � � (Phone) _Sl1� ` ` ! / � � '
(Address) , , e �� ��
(Address) (City) (Zip Code)
(Contact Person) _ � � �Y�
Phone
APPLICANT SIGNA'�JRE � __ --� �c..� t.�CG�.II.� A,I,E
APPLICANT PL S COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL `�" �C� p ��a ��� FUEL _(�
FLUE SIZE RETURN OPENINGS �p�
� OUTPUT J�`�
TYPE OF SYSTEM HEATING OR POWER PLANT �
❑Warm Air Plants ❑ Steaxn p�E�E NOTE: Air Conditioner
❑�G�avity ❑ Hot Water Unifs and Fireplaces Cannot Encroach
lv�'Ivtechanical into Re uired Side Yard Setbacks.
❑ Radiation 9
[�Air Condition;ng Fire laces with Box Additions or
❑ Special Devices P
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
FIREPLACE MAKE AND MODEL Require a Building Permit. �
Industriai, Commeroial & Multi-Famil o ��E SCHEDiTLE ��
Y 1/o of job cost Residentia(, Gas Fireplace " $49.50 ��
$49.SQ minimum " �
Residential, Heating & A!C (New Construction) $149.50 Residential, Additions & Alterations �
Residential, Heating Only (New Construction) $64.50 $49.50
Residential, AC Only $49.50 �
Estimated Cost $� .' b Building Permit # � �
, i . lie Ntinnesota Statutes � 32G[3.Id8
HEATING PERMIT FEE $�/ �� �� has been chun�ed lor one
STATE SURCHARGE y`ear ei�f'Lcti� e
5� Jul� !. ZO1(9. trt3ti: J�sitc 3i). 21l31.
TOTAI, PERMIT FEE $ ��(`]�_ Thc minimam surch for a"fised fec" permit
{Office Use Only) is :ti�, be�„i nning .1 uty 1, 2{)1(I
This Application Becomes Your Building Permit When Approved Paid
�, � � � Receipt No. ��� 7
Building Official Date / , /` `L By �
Date <�/� �'
24 hour notice for a!! inspections (952) 447-9850, fax (952) 447-0245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372