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� rRr CITY 4�' P1tIOR LAKE Date Rec'
°� � � ,;,'�� AEATINGiAIR CONDITIONING/FIREPLACE PERMIT
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�' " I. Pink Fil� ��IT NO . /� �.��11�
2. Green City � _ =r
j 3. Yellow Appiicaot V
, lease e or ' t aad si at bottom
; Ann�ss � � 1 ZUNING to�re ��}
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LEGAI. DESCRIPTION (office use only}
LOT BLOCK ADDITION PID
(Na� � A� �f}!( E II � (Phone) - �.�," �?�^ 91 �.FJ
(Address} � � S c� �, . _
APPLICANT " r /� /'^
(Naax�e) � T' l� (Phone) �� � • �7 ,���
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(Address) ! 1 �• • � � � �
( s (cz ) (Zip Code)
(Contact Persan) � V d hr ' (Phone)
APPLICANT SIGNATURE DATE "
,
PLICANT PLEAS COMPLETE BEL()W
QNEW CONS RUCTION REPLACEA+IENT ❑ ALTERATIQNS •
FURNACE MAKE AND MODEI., _`�� �� FUEL . S
PLUE SIZE RETURN OPENINGS INPUT OUTP[3T
TYPE OF SYSTEM HEATIIII'G OR POWER PLANT .
�warm Air Plants PLEASE NOTE: Air Condiiioner
❑ Steam Uni#s and Fireplaces Cannot Encroach
a G�ravity ❑ Hot Water into Required Side Yard Setback�.
[j Mechanical ❑ Radiation
�Air Conditioaing ❑ S�cial Devices Fh'eplacea wif6 Bog Addltions or
❑Vent. System ❑ Other Devices Cantilevers to #he Oatside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industtial, Commercial & Multi-Fatnily l% of job cost Resideatial, Gas Fireplace $49.50 �
$49.SQ minimum
Residential, Heating, & A/C (Mew Constniction) $149.50 Residenciat, Additions & Alterations $49.58
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $A9.50
Estimated Cost $ Building Permit #
Ttie Mini�esot� Statutes � 326Ei,1�8
HEATING PERMIT FEE $ � "SIiRCi-tr1RGF" hati been ci��a.nged I'or une
year effective
STATB SURCHARGE $ ,�.• f/Y) � ,1Fd�� t, 2U3u, untis ,�anc 30, 2o t L
TOTAL PER1t�CT FEE $�� � SQ T'hr minlmem surcha�^�e for a "Eisal Pec" �x�rmit
(Office 1Jse Only) is �,,,�, be�inning,tuly 1.201U
This Application Becomes Your Building Permit When Approved Paid �-� .� Receipt No. / 7�
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Date � Q/ I � By
Bapdias O�cial Date ,
24 hour notice for att inspectioas (95Z) 447-9850, fax (9S2) 447-42�45
4646 Dakota Str�t S.E., Prior Lake, Minneaot� 55372