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' � pRtp CITY OF PRIOR LAK�+ Date Rec'd
' ° �° ; � �'� HEATING/AIR CONDITIONING/FIREPLACE PERNIIT
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i �1MVES��P l. I'enk F�t� PERMIT NO. �� ��
2. Green CiTy
� l. Ycilow App�icaot
� Please e or 'nt and si at bottom
' ADDRESS C ZQNIlVG (offi� �Se)
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LEGAL DESCRIPTION (ott'ice use only)
LOT BLOCK .ADDITION PID
�a , i _L^'� ` I � � �l. V 1 � (Phone) "f"J� "l "1 � l�r�� .
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(Address} ��
APP�,IC � /� (�' / '�J�/�,
(Name) (Phone} �,"J��b" I U � i../"I V� �
(Address) � �� '� � � �:�`"/�� �
(Address) (City) (Zip Code)
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(Contact Persan) � � . � � � (Phone) '� -/� � � � �`� 4� �
APPLICANT SIGNATURE � DATE ��''
APPLICANT PLE E CUMPLETE BELt?W ,
QNEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS �
FURNACE MAKE AND MODEL FUEL
FI.UE SIZE TtETi7RN OPENINGS INPUT OUTPUT f%
'I'Yl'E OF SYSTEM HEATTNG OR POWER PLANT ,
❑Warm Air Flants PLEASE NOTE: Air Conditioner
❑ Steam Units and Ftireplaces Cannot Encroac6
❑Gravity ❑ Hot water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
�Air Conditioning ❑ 5pecial Devices 1�replsces w3th Bog Additiot�s or
❑Vent. System ❑ Other Devices Cantitevers to the Oatside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND M�DEL
FEE SCHEDULE
Industrial, Commercial & Multi-Family 1% of job cost Residential, Gas Fireplace $49.50 �
$�39.SQ minimum
Residenrial, Heatiug & A/C (New Construction) $149.50 Residential, Additions 8c Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only �49.50
Estimated Cost $ Building Permit #
Tlie Minnesota Stntutes � 32Gf3.148
"SURC;I-tnRGF.;" h�s been chfsn�ed I'orone
HEATING PERMIT FEE $ � year effective
STATE SURCHARGE $ �i. � .�n�,� s, 2{►�a. ►�T,r�� aunc ao, zui �.
TOTAL PERMIT FEE S Thc minimum surcharge for a fec" permit
(OPlice Use Only) '/ r /� n is ��, be�ianing .hdy 1.2U1U
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This Application Becomes Your Building Permit W6en Apgroved Paid �-� S� Rec ipt o. 1_� U��
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Bpildin� Officisl Date Date /`� �,�/ By
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24 hour notice ior all inspections (952) 447-9850, fax {952) 447-4Z45
4646 Dakota Street S.E., Prior Lake, Minnesota 55372