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(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N ame) 1'� �M �C �rCVAr1 er (Phone) 3 3 Co 702 0
(Address) , Q1.y0C�8_ C4 1 ' ,
APPLICANT f
(Name) �ie� �� e.�'G1 U (Phone) 33 (o ` `l 010 - 0
(Address) q320 13 L u f WS NW
(Address) (City) (Zip Code)
(Contact Person) (Phone) °7 L0 3 ' — 7F-S`
APPLICANT SIGNATURE DATE Z"Z
F/ APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM
HEATING OR POWER PLANT
❑ Warm Air Plants
❑ Steam
❑Gravity
❑ Hot Water
❑ Mechanical
❑ Radiation
❑Air Conditioning
❑ Special Devices
❑Vent. System
❑ Other Devices
FIREPLACE MAKE AND MODEL
rvJ-&Lk V 8 r % 1 °:Cs �c,�A ( afpr-�Eis
Industrial, Commercial & Multi - Family 1% of job cost
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50
Residential, Heating Only (New Construction) $64.50
PLEASE NOTE: Air Conditioner
Units and Fireplaces Cannot Encroach
into Required Side Yard Setbacks.
Fireplaces with Bog Additions or
Cantilevers to the Outside of Buildings
Require a Building Permit.
F.ctimated Cost $ '7C.Jt,./+
The Minnesota Statutes § 32613.148
" SURCHARGE " has been extended HEATING PERMIT FEE
until June 30, 2013, STATE SURCHARGE
The minimum surcharge for a
"fixed fee" permit is $5.00 COTAL PERMIT FEE
Residential, Gas Fireplace
Residential, Additions & Alterations
Residential, AC Only
Building Permit #
$ q, !go
This Application Becomes Your Building Permit When Approved
Buildine Official Date
h k . 4
$49.50 ��
$49.50
$49.50
Paid JV U
Receipt No. 4 f
Date S )
By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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