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CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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File PERMIT NO. z2 , 71_, Gree
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O(NamEeR) w/, t/L L A ! S (Phone) 15 2 - 1 440 /0V — 1
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(Address)
APPLICANT p
(Name) ,4 I di r L ---1- A C � .. (Phone) 95 , , . . _ ? : . % /64_, (Address) 7 3o M /e.2 44 /1ki) At- b
(Address) (City) / (Zip Code)
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(Contact Person) (C- M6t- Cfi '1_ f (Phone) 9C " g V /VG
APPLICANT SIGNATURE 0, . V a it I DATE S�/b'�9 °! Z-
/
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION D REPLACEMENT 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 0 Steam Units and Fireplaces Cannot Encroach
DGravity 0 Hot Water into Required Side Yard Setbacks.
D Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
DVent. System 0 Other Devices ev-s LiNI_ 'lo
Require a Building Permit.
FIREPLACE MAKE AND MODEL �� �tiP�`��
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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 5 V___
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid - i / s Rec pt N . /_ 57 1
Datef ii5, (2._ By
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245