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4 RI CITY OF PRIOR LAKE Date Rec'd
�� HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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INNESdiP 1. Fink File PERMIT NO . r
3 . Ye llo w Applicant ` ` City / / i /
3. Yellow �r�l�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
9 1 Es-l
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O (Name WNE ) R II fl +Ck*T) ( Phone ) g 1 V -1 � _' 1 / 7 "'�-�
1 �
(Address) the . • .A /M IL I1 L v a
APPLICANT
(Name) _ • _ . ,f I. .......-r _ L .4_ r WA °(Phone) O5V -1 /94C) 4)7(0
(Address) r _ AP, 'SS■ I 1 ' 1 i 44 f, (Addres (Ci ) t t (Zip Code)
(Contact Person) , . _ (Phone) ,s_e'1 —9i'7 ( _
APPLICANT SIGNATURE DATE J 0/ a I /
, ' ' ICANT PLEASE COMPLETE BELOW
❑NEW CO el " RUCTION El REPLACEMENT LTERATIONS
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 into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System 0 Other Devices Cantilevers to the Outside of Buildings
leak Ft C /e APE'1� Require a Building Permit.
FIREPLACE MAKE AND MODEL ''�`. /
` FEE SCH 1 -
Industrial, Commercial & Multi - Family 1% of job cost Residential, Gas Fireplace $49.50
$49.50 minimu
Residential, Heating & A/C (New Construction) $149.50 ' est I en to , ' I ditions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
L' - + 4 - 1. " Cost $ Building Permit #
The Minnesota Statutes $ 326B.148
"SURCHARGE" has been changed for one HEATING PERMIT FEE $ 1 19 r
year effective STATE SURCHARGE $.
July 1, 2010, until June 30, 2011. TOTAL PERMIT FEE $
The minimum surcharge for a "fixed fee" permit
is $5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid sL sv RI ipt No (
Date ( ' i' 77 �� vv
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