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' � rRxo CITY OF PRIOR LA,KE
h �y �ATIlITG/AIR C ONDITIONIlVG/Fg2EpLACE PE Date Rec'd
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� I. itink Fa� pERMIT NO. ��
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LEGAL DESCRIPTI4N (oflice use onlyj ' �
LOT BLOCK A.DDITION
PID
�OwrrEB �,��J � � � � �
� ���-��L�. (Phone)
(Address) _ :
c=;;. .
A.PPLICANT
(Name) `' �� '
:� :V HE1�TlNG & AIR INC. tp�one)
(Aaaress) 5182 V►1F_ST BR
� 763-535-20p4 ccity�
(Contact Person) (Zip Code)
(Phone) �
AFPLICANT SIGNATURE -
DATE
APPLICANT pLEASE COMPI,ETE BELOW �
❑1dEW CQNSTRUCTIpN REpLACE NT
FU,RNACE MqICg AND MQDEL � y� �� �(� L�( D C� ❑ ALTERATIONS ,
FL,UE SIZE � �� � FUEL
RETUItN ppENINGS �p�.
TYPE OF SYSTEM • d DUTPUT
HEATIIITG OR POWER PLANT
�Vann Air Plants
❑ Steam . pLEASE NOTE: Air Conditioner
[��" �� ��� Units and Fireplaces Cannot Encroach
❑ Hot Water
[]Air Conditioning ❑ Radiadon � ittto Required Side Yard Setbacks.
❑Vent. System ❑ SPecial Devices -' Fireplaces wit6 Boz Additions or
❑ 4ther Devices Cantilevers to the Qutside of Buildings
� MAKE AND M4DEL Require a Build9ng Permlt.
Indust�ial, Commcrciat & Multi-Famit o �E �CHEDIJLE
Y i/ of job cast Residential, Gas Fireplece
Residential, Heat' �a4.5Q minimum $44.50 =
Residential Heatin� O n�C Mew Consttuction) $149.50 ' Residentia l, Additions & Alterations
8 y (New Construction) 564.50 $49.50
Residencial, AC On)y $49.SQ
Bstimated Cost $ � �WY � Building Permit #
T1�e Niironsota Statutes ,��' 32GQ.148
, HEATING PERM.IT �EE $ _�5� "SURC:FiARGF.'" Ii�s been ch�n�ed Ibr nne
STATE SLIRCHAR�rE $ ve�r eifcctivc
TOTAL PEgMIT FEE • J�i!►� 1, 2tfie unti3 .)tinc 30 2011.
(OP(ice Uae Only) $ , � ?'hc minlm�un surchar�c Cor a"P�ed pec�� rermit
This Apptication Becomes Your Butlding Permit When Approved Paid is,�'{' bcgtnnin�.t�dy 1 . 2o�u
�f , � Receipt No. / / /j�
�D �0 7
BuildlueOfRci»I Date pr gY
bate d �y
24 hour aotice for ��t inspections (93z) 447A850, fax {952) 44q '
4646 Dakota Street $,E., Prior Lake, Minnesnta SS372 .
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