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O CITY OF PRIOR LAKE Date Recd
9
HEATING /AIR CONDITIONING /FIREPLACE PERMIT l /
�NNESO�P 2 . I. Pink k en F City PERMIT NO. // 974
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS _ ZONING (office use)
/570 /21 /Tel'eu- Cis-.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O(NWNameE) Ch,'k -/ a - MR y)� 6(04/ (Phone) / O �rt�
'!, / � � Phone ) r
(Address) /J I ? GQ /47%E// £;ft: J
APPLICANT _ • L,1�/�7 •
(Name) / ' 0 P7 iC (Phone) 2 / /N f
(Address) 6700 / " i.E1 -/ ,; // e& ,c• Ili/ a 55772
(Add ess) (City) (Zip Code)
(Contact Person) / a 7 I/ I/ • a (Phone) 9- `•""v // / v
APPLICANT SIGNATURE cliff �/ /fir DATE 09 - i
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
❑ Mechanical into Required Side Yard Setbacks.
❑ Radiation
DAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
AND MODEL 6 -1 c/Anr f 702 -
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
ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, SEATING PERMIT FEE $ I0
The minimum surcharge for a iTATE SURCHARGE $
"fixed fee" permit is $5.00 S
'OTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid b , / 3 -0 Receipt No./ 6 Z
Building Official Date Date z z / By ///
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 /
4646 Dakota Street S.E., Prior Lake, Minnesota 55372