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4 r RI CITY OF PRIOR LAKE Date Rec'd
° � � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� �
�I�'NES��A '. P`� F"e PERMIT NO. .
z. �� c�ry /� _
3. Yellow Applicant
lease e or ' t and si n at bottom
ADDRESS � ZONING (ot�ice u�e)
/ �3 ?D r� ��
LEGAL DESCRIPTiON (oti'ice use only)
LOT BLOCK ADDITION PID
o�R �� ( ��+M �� = 9��
(Name) (Phone) � '
(Address) � `-[ �j �Q � � � I Y' , --C�- ` ► ► �v
APPLICANT� _ ,/
(Name) !� n�r� PU � � � � (Phone) `�/� � "� ��s ' �YQ
(Address) `1 �i,� d��.Y'C;Y'��� b� v d N� 5�B �� 17�� 5�N ���7c�j
�/ (Address) (City) (Zip Code)
(Contact Person) �D z � h �� (Phone) `7l0 3 `7PS� " � �
APPLICANT SIGNATURE DATE �` �7az
PPLICANT PLEA E COMPLETE BELOW
�NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL ,'�� RC� m 6�O�G �I�S FUEL �GuF��t�1/!�� C�s
FLUE SIZE RETURN OPENINGS INPUT [�j� OUTPUT S7L��
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
�Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gr�vity ❑ Hot Water into Required Side Yard Setbacks.
,�]'�echanical ❑ Radiation
�r Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
� - �'w� � �-��� �- n �s�'�.Y-
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 �j
until June 30, 2013, HEATING PERMIT FEE $ �-/ � sO
The minimum surcharge for a STATE SURCHARGE $ ���6"�
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ �l�.
This Application Becomes Your Building Permit When Approved Paid� I 5 --� R e' t No/ �' lJ(D / l
l0 C1
Date s-- Z.� � /Z
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