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(0) CITY OF PRIOR LAKE Date Reed 4 -,,,• HEATING /AIR CONDITIONING /FIREPLACE PERMIT
IfINESOo 2. Gr cn c.;• PERMIT NO.
j 3. Yellow Applicant ( / ' / ZOS
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
lug 3 Mif °Kok Ci rc le 1U Prior Uc,Ke_ r10 SS
•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �� ,�
✓V
(Name) ja • "C..� fQ.. ►' kICA.vQ_, (Phone) 9Sa - L/q-C" C i/Cq
(Address) SAM •
APPLICANT ,�,, I
(Name) f ge-il ��}'( ► IosZ.. AGI d- Coo I i / l � (Phone) C oS�' 9e' ((l o� (Q
(Address) 5(� b S(A.) I S St. site. . a� rbrSt l ccKIL fhliu cg.), 5
(Address) (City) (Zip Code)
(Contact Person) I 012_1 i e...-- (Phone) (
APPLICANT SIGNATURE i� • g ita `.,2 DATE //- / - / 1
APPLICANT PLEASE COMPLETE BELOW ,
DNEW CONSTRUCTION p� REPLACEMENT ❑ ALTERATIONS .
FURNACE MAKE AND MODEL (ocx , k \CLf 6101 /480 jot) FUEL (k t
FLUE SIZE if RETURN OPENINGS INPUT /..X.) X OUTPUT So K
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warn Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical into Required Side Yard Setbacks. •
❑ R adiation Fireplaces with Box Additions or
(Air Conditioning ❑ Special Devices
❑Vent. System El 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 $ ({i 76(_) - (1 Building Permit #
The Minnesota Statutes ` 32611.148
"SURCHARGE" b
E" has been changed for one
HEATING PERMIT FEE $ j'/9 50
year is t lye
STATE SURCHARGE $ 5 • 00 .•' ,J uly t, 2010. until June 30. 2011.
TOTAL PERMIT FEE $ j 4 . TO the minimum surcharge for a "fixed fee" permit
(Office Use Only) is SS, beginning July 1. 2010
This Application Becomes Your Building Permit When Approved Paid CI) pt No. 6 �� L.3 Date r I . it y ` CY
Building Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372