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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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`�INNESO'��' �. P �"� F11 PERMIT NO. /� ¢�
2. �� c,Ty
3. Yellow Applicant
lease e or rint and si at bottom
ADDRESS ZONING (oBE'ice nse)
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" � YG V s
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ]
(Name) l�+D' Y"7' V� '�'� �v� � (Phone) � ' � �d' ���
(Address) � j '(.i(i G /� I�G�/ Ol� f^��� � J��J�
APPLICANT `� D
(Name) ✓ (Phone) � � �
(Address) � D'' � �L r�� �.
(Address) (City) (Zip Code)
(Contact Person) C.L �� /�� �� hone) V�' ���
APPLICANT SIGNATURE DATE � �
APPLICANT PLEASE COMPLETE BELOW
❑NEW ONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL 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 5etbaclzs.
❑ Mechanical ❑ Radiation
� Air 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
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 Conshuction) 64.50 Residential, AC Only $49.50
"' "' ' ' "ost $ Building Permit #
� The Minnesota Statutes § 32C$.148
"SURCI IARGr" has been changed for one �EATING PERMIT FEE $ ���
year effective ,
.luly i, 2010, u�atil .�une 30, 2�1 �. �TATE SURCHARGE $ �$'
The minimum surcharge for a "fixcd fee" permit COTAL PERMIT FEE $ � ��,�
is �, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid��/_� t Re i No. /��/ �
-�r— �7 V CQ (o
Date � // B
Buildin¢ Official Date (p � � �
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372