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CITY OF PRIOR LAKE Date Rec'd
,, O P, P i e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
Q+ . Pink File O /� O /'
�j�'NES� 1
2. Green Cit PERMIT NO. N � Gy/} 9
3. Yellow Applicant (/ /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
L1(5? V\\ c \New \U
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER , E 621 go 1z
(Name) � 1 A l �.�ateN 1 (Phone) 3
(Address) 1 i.% 57 Y a '\ \ iekk) 0 u
APPLICAN
(Name) tS011 ete-CA AkCOS , 1 nC � . ! (Phone) fi r„
(Address) \2D IC
D IQ 0i �r1C /V. \a.Yd auk et `1 )
(Address) (City) 41-M r (Zip Code)
(Contact Person) _ a ILO (Phone) (f l - - S JS5
APPLICANT SIGNATURE 4\Y`tIA, . V‘( 6 DATE C I' 2, -01
APPLICANT PLEASE COMPLETE BELOW
LINEW CONSTRUCTION Q ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
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.
❑ echanical 111 Radiation Fireplaces with Box Additions or
Air Conditioning ❑ Special Devices
❑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 $ 1 -1Q .
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ !.oO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paids -D , Recel o. 6 b3
Date, 4. C)' U c) By •
Building Official Date V /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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