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� p RIp CITY OF PRIOR LAKE Date Rec'd
° �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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'�1IN 1. Pink File PERMIT NO .
2. Green City �7 � �
3. Yellow Applicant L°
lease e or ' t and si n at bottom
ADDRESS ZONING (ot�ice use)
`�"� � � � ��� � �� � 5�-- - � `c..,
LEGAL DESCRIPTION (oflFice use only)
LOT BLOCK ADDITION PID
�aWNER � r � � � � � G�'" Y (Phone) "1_�r � J 1l�e( x "
(Address) '" 1 � � `�, U � U �� _ � f'` � C� �. I �, � 1 � V J � 3�
APPLIC �� ' ^ � � S� o� ' �1 � � �` a "1
(Name) � L. (Phone
(Address) 1 � � b� � �� L.�� 0�� � J � � !�� p--� `l� '�� -�,� � �
(Address) (City) (Zip Code)
(Contact Person) �'1 �'Z- (Phone) � �/ °� 'u ��-� � � � `�1
APPLICANT SIGNATURE DATE � — � —'
APPLICANT PL ASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE j A D MODEL ��_�'�'�' g �g T�►� � V�Q O• r� FUEL C/��
FLUE SIZE � � V C RETURN OPENINGS INPUT U O OUTPUT S 7(pO0
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
❑Air Conditioning ❑ Special Devices Fireplaces with Bog 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 �ost $ Building Permit #
"SURCHARGE" has been extended �� S j
until ]une 30, 2013, HEATING PERMIT FEE $
The minimum surcharge for a 3TATE SURCHARGE $ S50
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ 5 d
This Application Becomes Your Building Permit When Approved Paid J t'�� R ce' t No. ���S'/
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Date� 3� � L 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