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HEATING /AIR CONDITIONING/FIREPLACE PERMIT
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�� 1. Pink File PERMIT NO
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NNEso 2. Green City /3 `/ 7
3 . Yellow Applicant , v
(Please type or print and sign at bottom)
ADDRESS , (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID , 45 -- - i s-v_ tI Q 7-0
( me) R . `(11". SsS S S S) (cC `ti ' ie) Q (Phone) Iki` °'� O ti-s5 34 "a''
(Address) ( .--Q ) \ ■ \ _S S . S
APPLICANT 1 -, C. S a -� i
(Name) ^ i 9 L (Phone) l .S '1 �f7 -g I ay
(Address) \ 1 V 0 k\ <v(' 'fA1f 1,, e ,, 0 -- `-„\ OA,
(Contact Person) ' . c_.0 L y (Phone) - "1W)11 a
APPLICANT SIGNATURE DATE \ — — )
APPLICANT PLEASE COMPLETE BELOW
❑ NEW CONSTRUCTIONREPLACEMEN // �,, El ALTERATION
FURNACE MAKE AND MODEL 0 LAN � , 11 (cSZ t o �V • FUEL G
FLUE SIZE RETURN 0 'NINGS INPUT 1 QO, c OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner
O Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
O Gravity O Hot Water into Required Side Yard Setbacks.
O Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning O Special Devices Cantilevers,to the Outside of Buildings
O Vent. System 0 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 $ _ 3.Q , Building Permit#
HEATING PERMIT FEE $ "\ ( 1 S
STATE SURCHARGE $ 5.0
TOTAL PERMIT FEE $ ,Pit. 47)
This Application Becomes Your Building Permit When Approved Paid • t1. t ?) A5 Receipt No. 12._ /, 3
Building. Official Date Date b /�i�..7 By 1
24 hour notice for all inspections (952) 447 -9850
4646 Dakota Street S.E., Prior Lake, Minnesota 55372