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O � p RIp�� CITY OF PRIOR LAKE Date �tec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
N '�
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U
� '. p �"� F ''° PERMIT NO.
2. Green City
3. Yellow Appiicart
ease or ' t and si at bottom
ADDRESS , ZONING (oflfl�ce ase)
��1 a �-v V �- � f�c�.,
LEGAL DESCRiPTION (oflf'ice use only)
LOT BLOCK ADDITION PID
(Na���,�'� ,��) ��fC-� (Phone)��- Go�a
(Address) � "�'
APPLI T p �
(Name) � � ��3 � (Phone) C1.SZ- ��� �.�
(Address) ��� � 4����/V � � l�Wl/� � �Q ��ti1 ��� N�" l j�
(Address) (City) (Zip Code)
(Contact Person) � Phone) �
�
APPLICANT SIGNATURE DATE � �' � �
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODE L�y1a Q�f t,� 3� Y��Gu�O�U 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 Boz 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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
HEATING PERMIT FEE $ ��(,� �� "SURC[-IARG�" has been changed for one
STATE SURCHARGE $ 5,�� year effective
July l, 2010, until June 30, 2011.
TOTAL PERMIT FEE $��"� The minimum surcharge for a° fixed fee" permit
(Office Use Only) is 55, beginning July 1, 2010
This Application Bec mes Your Building Permit When Approved Paid ��� Re e' t No. /_�r'� (�
. (.f� �
Date � �/, ��
Buildins Official Date � Tl �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372