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�� p RI CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT � �� � Z
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�I�'NESO�� 2. Green City PERMIT NO .� �• /_�
3. Yellow Applicant �Q
Please e or ' t and si n at bottom
ADDRESS ZONING (oflFi�e �e)
(� C� <k �� C�: r� � wl°'i 1�
LEGAL DESCRIPTION (oflf'ice use only)
LOT BLOCK ADDTTION PID
OWNER � lLl >�
(Name) ��. ' � V G (Phone) ���� 7� 7 � .3 y � 7
(Address)
(Name) � G.. � (Phone) ���� ""`7� 7 �7�11 D
(Address) y �► S t� � 0'a l) /� �'� I/`j 11 /` ��L�� ��� ��� ��
(A dress) (City) (Zip Code)
(Contact Person) i.��� �''+���� (Phone)
APPLICANT SIGNATURE DATE �" s�" DI �
APPLICANT PL ASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MA AND MODEL FUEL
FLU 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
�ir 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
FEE SCHEDULE
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
�ost $ Building Permit #
The Minnesota Statutes § 326B.148
" SURCHARGE " has been extended HEATING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $
"fixed fee° permit is $5.00
This Application Becomes Your Building Permit When Approved Paid�� R ei No /�/'
�— �0 �P
Buildin¢ Official Date Dat� ,�'` � B y
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372