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�� p RIp�� CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�In'NES�ySA `. P�� F"e pERMIT NO.
z. c�e� c�ry
3. Yellow Applicant �
lease or 'nt and si n at bottom
a�DD�' SS I(�'3�� �� bv � l J ^� ZONING (ofleice �e)
'�Y� S3 Z
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �
(Name) � � �S Q 11(1 ��Y (Phone) LQ I o� — � I (p — 'J'JO O
(Address) b� �p o�2, -t Pr � o�' �ctK� J S Z
APPLICANT ,
(Name) BURt�SVILL� NiE�1'1t3G"&AIC, INC. (Phone) GSa"p'i�N�ObS
3451 W. Burnsville ar way
(Address) Suite 120
Bumsville,�9 �c�ry� (Zip Code)
(952)894
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE (p� f I Z
APPLICANT PLEASE COMPLETE BELOW
F��� ❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
-�VIAKE AND MODEL � I�J �'CN 1'� O�I Z. ��� Y�I Cl V l� 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 Bog 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 Construction) $64.50 Residential, AC Only $49.50
The Minnesota Statutes § 326B.148 �'ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, 3EATING PERMIT FEE $ yq� ��
The minimum surcharge for a iTATE SURCHARGE $ 5. o0:3fr
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ �� .�
This Application Becomes Your Building Permit When Approved Paid�, /�� Rece' o. 6��� �
Y" (Q
Date � � �, j� �
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