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' � Pxlp CITY 4F PRIOR LAKE Date Rec'd
� , °-h -r�� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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: ��NNESO�� �. r��k File pERMIT NO.�Z � 3��
� 2. Green City
I J. Ydloa� Applicant
(Please e or rint and si n at bottom
' AI?DRESS ZONTNG (oE�ce use)
� � �� �
LEGAL DESCRIPTION (oE�ice use only)
LOT BLOCK ADDITION PID
OWNER � ` �
(Name) e (Phone) � ��— � "'
(Address} �� �� �
APPLICANT
{Name) • • ' ' (Phone)
an a
(Address) 130 Plymouth Avenue N 45
inn '�p�1is
8� z�824 (Ll��ss) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE
APPLICAN EA E COMPLETE BELOW ,
ONEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS ,
FURNACE MAKE AND iVtODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT �
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plancs PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical ❑ Radiatioa into Required Side Yard Setbacks.
�Air Conditionin Fireplaces with Box Additions or
B ❑ Special Devices
`�[]'t�ent. System ❑ Other Devices Cantilevers to the Outside of Buildings
,�M �„r►� �/3 3%Z��j.� Require a Building PermiE.
FIREPLAC� N�AKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi-Family I% 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
Fstimated Cost $ � f�� Building Permit #
f'lie fViinnes<�ta Statutes � 32G13.1�1$
/� "SI:RC;f-1�1RCil;" has bern ch�zn�ed li�r one
HEATING PERMIT k'BB $_____� ycar efTeciive
STATE SURCHARGE $ � .)i�l� I, 2i�t(f trnti'. Jtiqc 3{) .1t�11.
TOTAL PERMIT FEE $ "I'hc minimum surchar�;c for a "fised fci" permit
(Off3ce CJse Only) is,�,�, br„innin�.tnly 1.201U
This Application Becomes Your Building Permit Whea Approved Paid �, ` S -v Re ipt 3�1a � S 7
.
Date � r y �� B
8uildine OfFcial Date
24 hour notice for all inspections (952) 447-9850, fax (952) �347-�1245 .
4646 Dakota Street S.E., Prior Lake, Minaesota 55372