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(iv RiO CITY OF PRIOR LAKE Date Rec'd
9 HEATING /AIR CONDITIONING /FIREPLACE PERMIT
M
4111VNESO 'S1.* I. Pink File PERMIT NO .
2. Green City /1 _. d 19,7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
'1 1 ' 3 a b GAL o c1—SI
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 5 \.. ,,k4, f ' , '� L` y k \ ' \ Q \,k 2 (Phone) 4 -C l �1� - S g 1
(Address) y . a 3 - (.\`(, 11 f t �� ,
APPLICANT ‘ ` l
(Name) N..\ \)- .___\,,_r\ (Phone) C A g a 4
(Address) \ 7f ° k\ L d i k . V \. ' r ; L i. c-- S 3
(Address) ___ Q (Zip Code)
(Contact Person) cnt, V\ l " (Phone) 1 C " \ A L A 1 O ), M
APPLICANT SIGNATURE ` I DATE :1 I O \1
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION )J REPLACEMENT ❑ ALTERATIONS )
FURNACE MAKE AND MODEL 6,-- ( k V
3 CRAW oLiS ,*(0 FUEL ! 6\1-
FLUE SIZE '31' PV (- RETURN OPENINGS INPUT k.) 0 do OUTPUT Cie ca)
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 /( ` i ❑ Radiation
it Conditioning 1p ( NV R s y ❑ Special Devices Fireplaces with Box Additions or
❑ System 111 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
i ne lmnesota statutes g .,z01:5.I46 nst $ Building Permit #
"SURCHARGE" has been changed for one S�
year effective [EATING PERMIT FEE $
July 1, 2010, until ntil June 30, 2011.
The minimum surcharge for a "fixed fee" permit TATE SURCHARGE $ S SSO
is 55, beginning July 1, 2010 OTAL PERMIT FEE $ 54 Sj
This Applic tion Becomes Your Building Permit When Approved Paid s7 S� OJ
Receipt No. O/ 9
i dOfcia I Date By Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372