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PRtp CITY OF PRIOR LAKE II ate Rec'd
- r 4 � HEATING /AIR CONDITIONING /FIREPLACE PERMIT
4
i 2 Ye
1. Pink Flee C ity �/� /O3 //]
PERMIT NO `
.
3. Yellow Applicant ` «`LLL ///
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I 56o Sreei u Po g Road cCE
LEGAL DESCRIPTION (office use only) \J
LOT BLOCK ADDITION PID
OWN
deW N1 I i t (Phone) q52-
(Address) I 3 0 br Point goad <S E
APPLICANT ( � � j�
(Name) O I IV Rou r (Phone) T LJ 1
(Address) I C i 01 4 V I M 1 1 V r 1 S 1 H QStI 1' 56 22:,
(Add ess) (City) (Zip Code)
A 1 — I
(Contact Person) _ A ,' __ 1 . (Phone) /, II •
APPLICANT SIGNATURE �� � , "• DATE - I ET LD I I
If
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION XREPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL F t OSS 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 g(Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
DAir 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
Inc 1V11111ILsUla oiaiuwa y JLu1S. i4o �'ost $ Building Permit #
"
SURCHARGE' has been changed for one
year effective IEATING PERMIT FEE $
July 1, 2010, until il June 30, 2011.
The minimum surcharge for a "fixed fee" permit STATE SURCHARGE $ .50
is S5, beginning July 1, 2010 'OTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid _ Rec ' t No. / ,/" ZZ
Date �� B
Buildine Official Date •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372