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pRt CITY OF PRIOR LAKE Date Rec'd
A ° ,: HEATING /AIR CONDITIONING /FIREPLACE PERMIT
SP
411 n'NES o0 " reen City k 2: PERMIT NO / / /268
G
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (Office use)
/ (Y C3 — CQ Pax Icvi ve_ S� —
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) D{ ( (X V1 ll re✓ l (Phone)
(Address) IL 0- ce `f Pa v- Vv i ecD Y e
APPLICANT
(Name) G + (LV% (Phone) 9S0/- -1 427 — 1 8 q 1
(Address) 1200 1 1 3 Vie* iA-1 i,iSVr Ile l■A• 5533 7
(Address) (City) (Zip Code)
(Contact Person) 1 1 °1 '
i S de- (Phone) Sa — 7( ' 7 1E •
APPLICANT SIGNATURE DATE 1 O — S : l
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION IS REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL Le. 04 SLP C IS v FUEL 1 d Q red
FLUE SIZE RETURN OPENINGS INPUT 9 , 91Y\ Q
OUTPUT / DO CAD
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 Fireplaces with Box Additions or
❑Air Conditioning ❑Special Devices Cantilevers to the Outside of Buildings
['Vent. System 0 Other Devices g
Require a Building Permit.
FIREPLACE MAKE AND MODEL i
FEE SCHEDULE
Industrial, Commercial & Multi- Family I "Ai 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 $ _5440 . t7 0 Building Permit #
The Minnesota Statutes (t 32613.148
HEATING PERMIT FEE $ r...iq, So "SURCHARGE" has been changed for one
year effective
STATE SURCHARGE $ 460 JoJy 1, 2010, anti: June 30, 2011.
TOTAL PERMIT FEE $ s 4. So The minimum surcharge for a "fixed fee" permit
(Office Use Only) is w,5, beginning July 1.2010
This Application Becomes Your Building Permit When Approved Paid 5-z /, S— Rece' No. 6 ,./
Date f/ � B
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372