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4 CITY OF PRIOR LAKE Date Recd
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y r HEATING /AIR CONDITIONING /FIREPLACE PERMIT / /s r /3
ilf, �P 1. pink File PERMIT NO. / 3 _ 0 , 41, �
NNBSO 2. Green City / .,-)\_
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
53// ASZVA 5f fR ls.6
LEGAL DESCRIPTION (office use only)
LOT 7 - - BLOCK / ADDITION / \ I Y S 7 f ° a y . / s Au N PID ,R5'-2Q -DAR -0
OWNER
(Name) r i c...".) Q , 11 b,...) (Phone) 6s 1- ?c '4
(Address) 5 9 L
APPLICA ) ,
(Name) l - ri �r LK kin 4-4/<, LL C_ (Phone) .9S - - 15 i) 0
(Address) _ r 9 ,14,' ' • e- ;D c- G-e-- A ,
(Contact Person) (Phone)
APPLICANT SIGNATURE 0 „ 4 1.‘ , u DATE S / & ^? 0 /3
APPLICANT PLEASE COMPLETE BELOW
NEW CONSTRUCTION REPLACEMENT ill ALTERATIONS
FURNACE MAKE AND MODEL 4 fl) ? T(4qJ S FUEL it/ -
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TY! OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
tJ Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑ Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
-Air Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑ Vent. System ❑ Other Devices 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
Cost $ Building Permit#
HEATING PERMIT FEE $ -Et) SURCHARGE $ 5.00
TOTAL PERMIT FEE $ ` S
This Application Becomes Your Building Permit When Approved , a' per' ® Receipt No./ fe
Da e ,�' By
Building Official Date (� ( 3
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372