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O (2, CITY OF PRIOR LAKE Date Rec'd
,,, . e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
7 1�r I. Pink File PERMIT NO. 2. Green City /2
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
S 5 5
LEGAL DESCRIPTION (office use only)
LOTOCCBLOCK00 k ADDITION C7 t... y1,3 W e-Z-�� 360 p 00 1. PID a 53 ‘ (")"
OWNER n
(Name) d 101/4.V1 v S 0-1A (Phone) (0 1 a- a ao -73D
(Address) sssw B roc &c 1.12._ Lim 43
APPLICANT„..
(Name) l) 4 C l ZJ "c -or (Phone) - 1 6 3Y $3 C)
(Address) ' k L a
(Address) (City) (Zip Code)
(Contact Person 1 �lt/1 t A. . (Phone) co 3 3V3 , 7 O
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
ANEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
ID Mechanical ❑Radiation into Required Side Yard Setbacks.
M Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
Vent. System ❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
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
Estimated Cost $ cz6 ob Building Permit #
The Minnesota Statutes § 326B. l48
HEATING PERMIT FEE $ Lief 5 0
St; RCI 1AR<i has been changed !'c» one
'car
STATE SURCHARGE $
_,�_ 000 Jul r , 2tiltl, naafi' June 311, 2011.
TOTAL PERMIT FEE $ _5_ y, 5 - 1 . 1w minimum surcharge for a "fixed fee" permit
(Office Use Only) is 'ms beginning ,1aaly I.211111
This Application Becomes Your Building Permit When Approved Paid 7 j Receipt No. / /D 7) d e
Date By
Building Official Date «1.
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372