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�°� �' HEATING/AIIt CONDITIONINGlFIREPLACE PERMTT
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i �^�°� � 3�� PERNIIT NO. � Z_�L�/, �
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' .ADDRESS ZONIl�TG (o� �)
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� LEGAL DESCRIPTI4N (oBfice use onty)
LOT BLOCK ADDITION PID
(Name) �1C���� � C�����1� J���"� t �� (Phone) �'��7' � Vi � ^ �( ���
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(Address) � berdeen Street t�E
Ham I�ak c�r} c� ��
cco� r�n� c��e, � �,3 - �3� - 7 7 � ?
APPLICANT SIGNA � �. DATE C � � �
A►PPLICANT PLEASE COMPLETE BELOW
ONLW CONSTRUCTION LACEMENT ❑ ALTERAI'IONS
FURNACE MAKE AND MODEL � Z � FUBL ��, ���Q�
FLUE SiZE RETURN PpVINGS INPUT OUTPUT
TYPE OF SYS'1'AVI HEATING UB POWES PLANT .�
�'Warm Air P�nts , �� PLEASE NOTE: Afr Co�diiioner
�Cuavity O Hoc wacer uni�s xnd F�replaces caaeot Encxoach
� Machanical ❑ R,adiation into Reql�ire@ Side Yard 5etb�tcics.
►ir Coaditionin8 ❑ Spxial Deviaes � wif4 Boz Additions er
Qv��. s� p o�� c���ra t� t� oer�ae or B�a�B
Reqeire a B�iWing Pern�
FIREPLACE MAKE AND MODEL
FEE SC�DULl�:
Induatrial, C.ono�aa! dt Multi-Family . i% of job c�t Residential, Gas Fireplace - 549.50
�49.SQ minimnm
Resideutial, Heatmg dt A/C (New Ca�on) $144.5(f R�esidential, Additions & Al�#ons 549.50
Resi�den6al. Hsaii� On1Y (New Conatrndia�n) 564.50 Residmitial, AC Only 549.50
Estimabed Cost $ �.,,�� Buildit►g Pe,rcnit #
The Minnesota Stt�tates � 3266.148
HEATING PERMIT FEE $�� ,� b "SLRCHARGE" has been chart�ed for one
year ei'r'�ctive
STATE SURCHARGE S_,5. 'J d � .)uty t. Zt�:U, u»ti� asnc 30. 21t! l.
TOTAL PERMIT FEE s �j ,�� T6c d�inimam surcNer�Ce for a"fiaed fce" pennit
(pp� �� p� is � bcRiania� .Iriy 1.2810
This ApgLScation Becomea Yoar Buikiing Permit When Approved Paici��/ � ReceiptNo. /� (O
T (P
s.�.so� u.� � 11�1-I�/L- By .
24 6our notice �r alt i� i952) 447 985�. fax (952) 447-42�15
4606 Dak,affi Street 3.E., Priar Lake, Miaaeeeta S�i72 .