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04 rRlo CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� �
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,� ,�� ,. P„� File PERMIT NO. J�'� 9�
NNESO 2. Green City
� 3. Yetlow Applicant
lease e or ' t and si at bottom
ADDRESS ZONING (o��,�)
� � ` `
(
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O�VNER (Phone)
(Name)
(Address) f , i � � " —
APPLICANT —C� �
(Name) � ( � ' ne),
(Address) � � � ���
Ad ) (City) (Zi Code)
�
Contact Person) � u- I'� '���� (Phone)
APPLICANT SIGNATURE DATE � a"�
AP CANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT TERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT pLEASE NOTE: Air Conditioner
� OWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
_�Gr�vity ❑ Hot Water into Required Side Yard Setbacks.
��echanical ❑ Radiation Fireplaces with Bog Additions or
�Air Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑Vent. System ❑ Other Devices
Require a Building Permit.
FIREPLACE MAKE AND MODEL f
FEE SCHED � � �
Industrial, Commercial & Multi-Family 1% of job cost Residential, Gas F' � $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 ^ost $ Building Permit #
"SURCEIARGE" has been extended �
until June 30, 2013, HEATING PERMIT FEE $ �
The minimum surcharge for a STATE SURCHARGE $ .50
"fixet� fee" permit is �S.C)t) TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid�l` t Receipt No. Q 7�
7�=�v
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Date i /�� By
Buildine Ofticial . Date �
24 hour notice for all inspections (952) 447-9850, faa (952) 447-0245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372