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o � p RIp� CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� �
`7INNES��� 1. Pink File pERMIT NO .
2. Green City � �� � �
3. Yellow Applicant
lease e or 'nt and si at bottom
ADDRESS � ZONING (ofleice use)
�d�� � f 'ZN1`�'' �1� 1� �
LEGAL DESCRIPTION (oflFice use only)
LOT BLOCK ADDITION PID
(Nam ) 1 � �� 1J � �` "T' Y 1'►"1 (Phone) l.� � �,O �'�U � � d�
(Address) 5 � a � r� � � ��� 1� t�► �
(Name) ANT (1^ � � f T 1 �^ .��� � (Phone) �� � — �I `1 � — O J �. �1
� V►`
(Address) 1 W `�� ��` (,C�� �Y � �(� � 1� � �-�,I� S� 3� �,
(Address) (City) (Zip Code)
(Contact Person) � ��'` s � \ �• (Phone) 5 � a �y "� — a J � `7
APPLICANT SIGNATURE DATE �
APPLICANT PL ASE COMPLETE BELOW
�NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL h� �I �• � � � �b � � I FUEL � �1� —
FLUE SIZE �� V RETURN OPENINGS INPUT � �� OUTPUT ��p g
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 �Hn,� 1, y�-�, 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
T _` ' ' ^.ost $ Building Permit #
The Minnesota Statutes § 326B.148 �� s �
"SURCHARGE" has been extended HEATING PERMIT FEE $
until june 30, 2013, STATE SURCHARGE $ S 0
The minimum surcharge for a COTAL PERMIT FEE $
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid�i /� Receipt No. � �
��
Date d ) � �// � By
Buildin¢ Official Date d��
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372