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e RIO CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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4 I. Pink File PERMIT NO. ( r ^/
2 Ye llo w Applicant City 1 ✓"1� / _
3. Yellow ` .........JJJ,,,J fff///-"��"
(Please type or print and sign at bottom)
ADDRESS l ZONING (office use)
S ? (rosS 1/4 s+ - S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER '`-1 NI 4. ;
G � C 1�1 0 �
b A\ (Name) J x h �� (Phone)
(Address) - '7 ( v - S Ci & & C (.,
(Name) r"■l r _in L- Phone -- W7 g- 1 k k
(Address) I �O \ D Q A L U ft 11 U 1 k. r'1 c' �' � i l S 3
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(Address) (City) (Zip Code)
(Contact Person) 1 V C\h l y .0 (k ' ik) (Phone) C i A A -N4 —3 , a 4
APPLICANT SIGNATURE \•.- A DATE - ` S ,. 1 1
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION J:80 REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL Si)l ( .,k (.j V 0 bv - tiA 0 FUEL A) Cy+
FLUE SIZE 7 AN L RETURN OPENINGS INPUT O , 0 - V, OUTPUT ') \ � ) c
TYPE OF SYSTEM HEATING OR POWER PLANT
Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
Gravity ❑ Hot Water
❑ Mechanical into Required Side Yard Setbacks.
❑ Radiation Fireplaces with Box Additions or
Air Conditioning El Devices
❑Vent. System ❑ 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
The Minnesota Statutes § 326B.148 Mst $ Building Permit #
"SURCHARGE" has been changed for one S-9 year effective HEATING PERMIT FEE $
July t, 2010, until June 30, 2011.
STATE SURCHARGE $ S c50
The minimum surcharge fora "fixed fee" perm 4 -
$1, beginning July 1. 2010 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid 5 / Rec No. (Q333
Date 7 1' l /
Buildin¢ Official Date , •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372