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o � pRl�p�� CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�I�'NESD�P 1. Pink File
z . �«� � PERMIT NO. /� ��
3. Yellow Applicant � �
lease e or rint and si at bottom
ADDRESS ZONING (oflFice use)
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LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
OWNER t
(Name) � � �� � �- �l�! � (Phone) [�f.�'��� ����.
(Address) � � � ._ � YG'- c� - f'` c �l� �
(Name) � �7`��Z " (Phone) ���� 7 � � ��
(Address) � � � � _� �,' ��(�° e_ � ?.��� , ' ��i�� -
(Address) (City) (Zip Code)
(Contact Person) � - � � (Phone) ��� �"� �� /�`1 5�'""
APPLICANT SIGNATURE DATE � ���
APPLICANT PLEA 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
❑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 Box Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
equire a Building Permit.
FIREPLACE MAKE AND MODEL _�`c�":/!�� �/i2�''�� `���
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
The Minnesota Statutes § 326B.148 �'`%ost $ Building Permit #
"SURCHARGE" has been extended
unril june 30, 2013, HEATING PERMIT FEE $ . J�
The minimum surcharge for a 3TATE SURCHARGE $ s�
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ �"""� � ^ � ` ,s'� � J�(�
This Application Becomes Your Building Permit When Approved Paid � a � Rece' t o. �,�
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Buildin¢ Official Date Date �' ��� B ,
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
_ 4646 Dakota Street S.E., Prior Lake, Minnesota 55372