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04 pRlp� CITY OF PRIOR LAKE Date Rec'd
� 9 HEATING/AIR CONDITIONING/FIREPLACE PERMIT �U �� 2
� �
�I�'NES��P 1. Pink File PERMIT NO . �� I N��
2. Gceen City
3. Yellow Applicant �
Please or 'nt and si at bottom
ADDRESS ZONING (ofleice use)
��1 � � r�' ��'�V� .� �C �
LEGAL DESCRIPTION (oH'ice use only)
LOT BLOCK ADDITION PID
OWNER y C �fr� r
(Name) � I � � `� � (Phone) J� � I `� � ���
L
(Address) �
(NameCANT �, hone) � �� � �-l'� � V V �
(Address) � � w Y � ✓J�
(Address) (City) Zip Code)
(Contact Person) � � (Phone) J �� �-[�� � �
APPLICANT SIGNATURE DATE Z� Z
APPLICANT P ASE COMPLETE BELOW
�NEW CONSTRUCTION PLACEMENT ❑ ALTERATION5
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTP
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
DAir 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 KEATING PERMIT FEE $ �> �
until june 30, 2013, �TATE SURCHARGE $ .50
The minimum surcharge for a COTAL PERMIT FEE $ ��
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid � ,� Receipt No. /_/ ��Z
�-- lf/�0
Date By
Buildin¢ Official Date 1 U`�' � Z�
24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372