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�� PRI CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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� P 1. Pink File
� 2. Green City PERMIT NO . / l „� (�/�
3. Yellow Applicant � �
lease or ' t and si at bottom
ADDRESS ZO1�TII�TG (oflI'ice use)
� I.C.J �1 .�.�'
LEGAL DESCRIPTION (ofl['ice use only)
LOT BLOCK ADDITION 1'ID
OWNER � `�_
(Name) �����°� ��Uv\ (Phone)
(Address)
APPLIC r �� - � K �U� �/'? r� V
(Name) � (Phone) ��
(Address) � (� �� � ��� � � �. �/ J� �� 17/`Jt��,�--�.l�� IYl N � � ��
(Address) (City) (Zip Code)
(Contact Person) C:✓1 � (Phone) ��" � 7 7�� � � �_
APPLICANT SIGNATURE DATE �' ��
APPLICANT PLEASE COMPLETE BELOW
�NEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS �,
FURNACE MAKE AND MODEL FUEL �
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
�arm Air Plants ❑ Steam Units and Firepiaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Boz Additions or
,,�ir Conditioning ❑ Special Devices
�Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEESCHEDULE
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
�°*;m�rP� Cost $ Building Pertnit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended ,/ (J
until june 30, 2013, HEATING PERMIT FEE $ �'� � 7�• �
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ ,5� �
This Application Becomes Your Building Permit When Approved Paid ��/ ,71 Receipt No. Z a
�t-� v �
Date �f/ � � By
Buildin¢ Official Date �T
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372