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�� pR CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�j�'NES��P ,. p�� File pERMIT NO.
2. Green City
3. Yellow Applicant
Please or ' t and si at bottom
ADDRESS ZONING (oflf'ice use)
L. G i
LEGAL DESCRiPTION (oflE'ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) m 1 �1 �b I" 1 xl S�s— (Phone)
(Address)
APPLIC / n
(Name) !'' ) I�! G. ��c L �--�1 � (Phone) ��� � 7 "� � � U
(Address) �fv�S y �� �j� �/7�a � l�� � i-i ar ��..Xc �/� ��� ��
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS 1NPUT 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 Fireplaces with Boz Additions or
❑Air Conditioning ❑ Special Devices
❑Vent. System ❑ 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
��`=----`-' Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended HEATING PERMIT FEE $
unril June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid �_ ipt No��
Date ---
f/� � .
Buildin¢ Ofticial Date S � 1 �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372