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�°1 PRI°�C
CITY OF PRIOR LAKE Date Recd
v HEATING/AIR CONDITIONING/FIREPLACE PERMIT ��
drl�'NEj.!
12. PGreink en File PERMIT NO. /J•//45:6. City
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESSZONING(office use)
15LQLO 0 ( 9 IWC, AV (1 V/ RlSa
LEGAL DESCRIPTION(office use only)
1 r Q
C � �� PID 2". � 3 �� a
LOT BLOCK ADDITION . 5 .�.D Pi e� L
(Name) I H, D U JC- atit (Phone) VC I ((I) . Li QA l
(Address) IoQ I Hk i vii , C vt)
(Name)AppucAini. ,,,,-,, 147,,,cm
km:* ��
(Phone) / • /I
(Address) L®D . 6 i O DV
' or `�►"
Addr ss)n� 1,n (Cit'S il �� %.101(....9
(Contact Person) (1 fY\L a,�Vr �' 1 (Phone) `/`A�
•
APPLICANT SIGNATU' - �� J I DATE CA--21E61
A' 'L CANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION A REPLACEMENT El 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
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
0 Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices
❑Vent.System ❑Other Devices Cantilevers to the Outside of Buildings
K..01.1140-1--
�'/��]C /��7�J�jRequire a Building Permit.FIREPLACE MAKE AND MODEL ``• s �/,L'(/�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 $ LI CI 'C261
STATE SURCHARGE $ r 1.00
TOTAL PERMIT FEE $ �l
(Office Use Only) eic,
n
This Application Becomes Your Building Permit When Approved Pairby cO Receipt No. /
Building Official Date Dates` ` t<
By
24 hour notice for all inspections(952)44447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372