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(riR CITY OF PRIOR LAKE Date Rec'd
9 HEATING /AIR CONDITIONING /FIREPLACE PERMIT /Z._ Z,i/
L) M
1111 `(Q I Pi F
nNESO PERMIT NO / 1 / �9)
2. Green nk City /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
31-01 6 vi40 ps. ki-i A IOs ,1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) O �,� ' / kp i ■V\ j, I \ 4 (Phone) q 15 a - ' 1 {`H () ^ D375"
(Address)
APPLICANT
(Name) 1---Clik \\ 171 c-c� ? L .ES (Phone) 6, ( ' ii 1 ` - c . f rt - a
(Address) r.. \ D \ U E 1 v .,..\ . f� - E 1p (L,", (g t ( \A -J . S �U '--C�
(Address) t! _ (City) (Zip Code)
(Contact Person) "%' a- -c-- (Phone) G t a-9 \ , -4 r
APPLICANT SIGNATURE 4////6" " 41 DATE
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ 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 ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑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
r_`:.__ -` -' Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $ 11 50
The minimum surcharge for a STATE SURCHARGE $ , v.®
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ ,.5
11
This Application Becomes Your Building Permit When Approved Paid s ,/sv Receip o.6¢ 7z4
Date i z ' `/ By
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