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C NES R/ GITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT i e
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1. Pink Fle V 2. Green City PERMIT NO� cr,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWN) / a n ) r h i� (Phone)
( Address) ]f`
(Name) / (Phone) 0p / Z -3 66 - 3 /
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-2 � Pi Ne 27' � � „Q (Phone 7
(Address) 3 -6 A.Q{^� A i h,9 S . f 5f1/ 4,)/')e &2_ SSA' - 2 a
(Address) V (City) (Zip Code)
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(Contact Person) 4 in ee . 4 9 �P
� � � 0 G (Phone) ia - 3 &6' 314? '-/
APPLICANT SIGNATURE 1 / r/, !j 1 /� / jA DATE dr
/
APPLI ANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT 0,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.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
❑Air Conditioning ❑ Special Devices
EVent. System 0 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 $ 1 0 ‘2,9, Building Permit # t
1
HEATING PERMIT FEE $ I 0,:t2., �l 1 i � y ,
STATE SURCHARGE $ .SQd A ` J
TOTAL PERMIT FEE $ (0 S 00 jk0 `
(Office Use Only) •
This I h a
Becomes Your Bu'_5'_t '-
-- mit . he Approved Paid Receipt No. r��///���
f k 4' 3 ( Date By
B ` ; r 1 l 1 ate
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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