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04 P RI CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT �� ' �
� � � !
�j�'NE5��P 1. Pink F,�e pERMIT NO.
2. Green City � ��— � �
3. Yellow Applicant
Please e or rint and si n at bottom
ADDRESS ZONING (ot3cice use)
Ss' � � �►�..,.�i Cr. �.t� ,
LEGAL DESCRiPTION (oftice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address) �p �,�� .. � �,,�� � (,J �
APPLICAN / �/� /�
(Name) l " � .�I�C (Phone) c�'1���,7v� ��1�.
(Address) � � �Z 1 `Zo� 5.3'� �
(Address) ( ity) (Zip Co e)
(Contact Person) �l � S (Phone) (�ro " =�— ��o�-�
APPLICANT SIGNATURE � DATE
APPLICANT PLEA E COMPLETE BELOW
�� ❑NEW CONSTRUCTION ' PLACEMENT ❑ ALTERATIONS
�`OlZ�CE"MAKE AND MODEL T ��,?j ��� �� 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
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
� ir 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% 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 App 'cation Becomes Your Building Permit When Approved Paid � n 0 �„ Receipt No `�...
_ .. X (D
_� � fj� J� Date • C L By
Buildine Official Dat�e — '
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372