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� rRxo CITY OF PRIOR LAKE Date Rec'd
°»�'"���'����� HEATINGIAIR CONDITIONING/FIREPLACE PERMIT ¢� � ��
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; '7 '( 1. Pink Pile � s � l
; l N^� 5 O 2. Green cE� PERMIT NO. �
j 3. Ydlow Appticant �./
Please e or 'nt and si n at bottom
ADDRESS ZONING �o�re u��
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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(Name} a' �l �� �'� (Phone) l� I � � � �
(Address} ��� � 1� � �1�� � /'✓'�(�✓ l�Gc /� �/�
APPLICANT� �!' /� /,, � n
(Name) I �L b�i✓.� d �l` -Q f7lCl�S {�'hone) TLZ ' ` ��� "T
(Address) ��D �'ST / ��p Sti �7U! f'� 1 � � � ✓Y! SU/ ��� ///N � 3 '�
(Address) (C�tY? t��P C�)
(Contact Person) (Phone) �Q � Z ' � Y� "� "��
APPLICANT SIGNATURE DATE Z6I iZ--�
APPLICANT PLEASE COMPLETE BEL�W ,
QNBW CONSTRUCTION REPLACEMENT ❑ ALTERATION5 �
FUTtNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPU'T OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT �
PLEASE NOTE: Air Conditioner
�Warm Air Plants ❑ Steam Units aud Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Add3tions or
�Air Conditioning ❑ Special Devices
❑Vent. System ❑ Other Devices Cantilevers to the Ontside of Buildings
Require a Building Permit.
FIREPL,ACE MAKE AND MODEL IeS
FEE SCHEDULE
Industriai, Commercial & Multi-Family 1% of job cost Residential, Gas Fireplace $49.50 '
$�39.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
ltesidential, Heating Only (New Constntction) $64.50 Residential, AC Only $49.50
Fstimated Cost $ Building Permit #
'The Minnesota St�tutes § 326[3.148
HEATING PERMII' FEE $ �y � °SI;RCf-tnRCiF" hs�s been cht�nged I'or one
year effective
STATE SURCHARGE $ S- U .B0 �ul,• j, 20�0. �3�t�t ,Ja�nc 31) 20� t.
TOTAL PERMIT FEE $ ,S ,� 'fhc minima�n surchar�e for a " r.� r���� permit
(Of�ice Use Oaly) is �,.,�, be�inning duty t.201U
This Applicatian Becomes Your Building Permit When Approved Paid �� ,.. Re i t No.���� ¢
Date��� . ! Z B
Baildine Oificial Date •
24 hour notice for all inspections (952) 447-9850, fax {952} 447-42�t5
4646 Dakota Street S.E., Prior Lake, Minnesota 55372