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o. PRI0 CITY OF PRIOR LAKE Date Rec'd
A. ,/ e HEATING/AIR CONDITIONING/FIREPLACE PERMIT
4y P 1.Pink File PERMIT NO.
1NNEso 2.Green City /4 /3e6
yj
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING,(office use)
52 - i-\ h PO i v)-1--e C-f-,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Nam) k---)an Lo -C--1-U (Phone)Qszri i o- Rci ZZ
(Address) 552u1 vl V l t ni--( C+. Ph 6 iY L6t WI/ sa3 Z
APPLICANT 4ta-1-:0/9 p`(Name) u,1�I�)Sv1�1, Al 4 (Phone) q3Z gwa -
(Address) 3b\ W 't, i'\ \J lLC, (V.WL1 S>k RU 1jU\iiSVl lilt RN 5533;9-
(Contact Person) ,‘-)-- V\a h\t— (Phone)
APPLICANT SIGNATURE� -kMI )i(LJvA/— DATE /d-L/'/y
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTIONPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL"bNq ;AA I J N7 09 0 FUEL na-hAva 1
FLUE SIZE RETURN OPENINGS INPUT g0ay) OUTPUTTO Li 00
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.
2 vIechanical 0 Radiation Fireplaces with Box Additions or
0 Air Conditioning 0 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 $ Leg°
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ 94
This Application Becomes Your Building Permit When Approved Paid ( Recei No.3 L a..
Building Official Date Date .2._ l l By
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372