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� p RIp CITY OF PRIOR LAKE Date Rec'd
° �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�I�'NES��P 1. Pink File pERMIT NO . �
2. Green City
3. Yellow Applicant 1
Please e or rint and si at bottom
ADDRESS ZONING (ofitice �e)
J � V � � � �1 �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) /� L° II'�? � � �,/� (Phone)
(Address)
APPLICAN'�!� I r/ �� — � c , �" �� ` D
(Name) 1 i' 1 D i' L.�c.�.� ��.�.�� (Phone) 7
(Address)I � �O � �C�t7� � Ci ���/� (.�T_ /7D�"L�L �/��537�
(Address) (City) (Zip Code)
(Contact Person) (Phone) ��' � � 7"` �1 � �
APPLICANT SIGNATURE DATE S �
APPLICANT 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
,�C�arm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ echanical ❑ 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 Residentiai, 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
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 A at' n Becomes Your Building Permit he Approved Paid Receipt No. .�-�„
Z- Date r � 2_ By
Bmldin¢ Official Date J
t-
24 hour notice for all inspecrions (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372