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° �� HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�I+�'NESD�A t. Pink File
Z . ��„ �,�. PERMIT NO. /,Z —/�39
3. Yellow Applicant
lease or ' t and si at bottom
ADDRESS ZONING (oH'ice use)
5�2� CroS���c�rq � � �tC1� f��
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
��WNER ��� `�� ���� (Phone) � �/���
(Address) ✓<J �� �����/ � �l/I � �� l�� �� �� 7 L
(NameC � � �' +�� L '� �I � � hone) �� �
(Address) � / l�� I
� (Address) f ,, ,�, ' Code)
(Contact Person (Phone)
' ��{� � �J�����
APPLICANT SIGNATURE Y��� DATE I V1 ��'�
APPLICA PLEAS COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL � � FUEL �.Jv1
FLUE SIZE RETURN OPENINGS INPUT ����0 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
❑Air Conditioning ❑ Special Devices Fireplaces with Bog Additions or
❑Vent. System ❑ Other Devices 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 & Alterarions $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
The Minn�sata Statutes § 326B.148 Cost $ Building Permit #
"StJRCI{ARGE'° has been extended
until June �0, 2(►13, HEATING PERMIT FEE $
The minimum surc}�arge for a STATE SURC�IARGE $ .50
"fixed fee" permit is �5.d10 TOTAL PERMIT FEE $
__ _
This Application Becomes Your Building Permit When Approved Paid�, `�� Receipt No. 7 7 ��
7"
Date � 6 /Z By �
Buildin� Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372