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� pR CITY OF PRIOR LAKE Date Rec'd
F �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT �- 7 � 2
� �
+�p •tF' 1. Pink File /
j �'NES� 2. Green Ciry PERMIT NO . / 7
3. Yellow Applicant / �/ � �
lease or ' t and si n at bottom
ADDRESS ZONING (ofl['ice use)
/ � `7 �1' C� !�/ �v A L� . ��� .
LEGAL DESCRIPTION (oflCice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
�ame � � (Phone �'Z.Sc� �'� u � � � d
c� ) ` ) — 8
(Address) � ��- ° � ��
(Address) (City) {Zip Code)
(Contact Person) � (Phone)
APPLICANT SIGNATURE DATE � — � '" j �
APPLIC T PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
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
❑Gra�ity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
�Air 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
FEE SCHEDULE
Industrial, Commercial & Multi-Family 1°/a 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 � Cost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $
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 � s S Re ei No. � s—�
Date�, � , �.� B ,
Buildin¢ Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372