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O � P R1p� CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� � �o��� 7-c/�� � E
� 1. P � F ''` pERMIT NO. �
2. Green City � ) � / /l y �
.. 3. Yellow Applicant L•• f'O
Please e or ' t and si at bottom
ADDRESS ZONING �ot�re,�>
� "� v � �+.C//�1..
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
� ._ p /
� � `' � v l/' (Phone) L ��`"O�LD �',.1��
(Address) L' � � ' r �O �/ �^o'/`�[ g �
APPLICANT
(Name) ` (Phone)
(Address)
� � s� (City) (Zip Code)
(Contact Person) ����� hone)
APPLICANT SIGNATURE ` DATE I4� �
PPLICANT PLEA COMPLETE BELOW
ONEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS �
FURNACE MAKE AND MODEL y y��--UC� � S Pi�� FUEL �
FLUE SIZE RETURN OPENINGS 1NPUT ��4d�� 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 Boz 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 & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended �ost $ Building Permit #
until �une 30, 2013,
The minimum surcharge for a HEATING PERMIT FEE $ ��'��
°fixed fee" permit is $5.00 STATE SURCHARGE $ � C�
TOTAL PERMIT FEE $ ��� � •
(Office Use Only) �
This Application Becomes Your Building Permit When Approved Paid ��[ � Receipt No.� ��� �
l
Buildine Ofticial Date Date / �, j/ By �
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24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372