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p RID CITY OF PRIOR LAKE Date Rec'd
° = F i ,P HEATING /AIR CONDITIONING /FIREPLACE PERMIT 8 ` 2 i (
AY � ....._ o-P t. Pink City 2. Y PERMIT NO .
Green City 1 O
3. Yellow Applicant V r��-�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
IS ? - c){,n Pc ss NkA1
LEGAL DESCRIPTION (office use only)
LOT ^ t�C.� BLOCK ADDITION PID
((Na me)) R 1 w C if y h 4 (Phone) (pJ ' ) 1)7
(Address) ) s" -1 1-i �ln N 1.t
( ame C P 1 (P ) — I- % y
(Name) U�(rb [�� hone °�` S
(Address) 1 ( 1 915 6%3. 3 ..") Qh SSzl l
,� , ,Q (Address) I (City) ` Zip C
(Contact Person) R ""`� ` (i'\, , L [AAA l (Phone) c / - 1 (4 riz 7 % v/ 7 • APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
:NEW CONSTRUCTION PLACEMENT El ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
iP it Conditioning ❑ Special Devices Fireplaces with Box Additions or
[Went. 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 $ Building Permit #
The Minnesota Statutes § 32613.148
HEATING PERMIT FEE $ y q.J a "S(; RCE IARG has been changed for one
year effective
STATE SURCHARGE $ ,I au 758 duly 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ .'y, SD The minimum surcharge for a "fixed fee" permit
(Office Use Only) is .' beginning duty 1.2010
This Application Becomes Your Building Permit When Approved Paid 5 Re ipt No. 6 3 A 4 7
Dat Q B mot' //
Buildine Official Date v . Z. i
24 hour notice for all inspections (952) 447 -9850, fax (952) 4474245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372