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,4 e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
it t li
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�llANESOo 2 . Pink File
2. GreenC City PERMIT NO. / / - U 0 c
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS i • � 1 Pi � ZONING (office use)
, VIJI
LEGAL, DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1(i K '/ ry
(Name) V< -1.,A � (Phone) Lei I ai v` OW ( J
(Address) 0/1 i --() () d (lc { 1i .
(Name)
APPLICANT (Phone) • 5D- ' ' 10- iV'Uu
(Address) C)avV 'kW,' 3 11"v Qu UW ( `\ VY - ��
(Address) (City) � (Zip Code)
(Contact Person)
R- � Re- t 11 /� (Phone) ` .�tS� 6 ' 1 U
APPLICANT SIGNATURE �! la. �= . .1 _/O DATE M1( T1 (
APPLICANT PLEA E COMPLETE BELOW
ANEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants ❑ Steam
Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical El Radiation into Required Side Yard Setbacks.
Atint Conditioning 0 Special Devices
. Fireplaces with Box Additions or
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 $ c))45, Imo_ Building Permit #
The Minnesota Statutes §§ 32613.148
HEATING PERMIT FEE $ I.S "s1 ;RC1!:1RCir has been changed !Or one
year effective
STATE SURCHARGE $
�/(� July 1 , 2f110, until June 30. 2011.
TOTAL PERMIT FEE $ 5 5 0 The minimum surcharge for a "fixed fcc" permit
(Office Use Only) is ti,,, be 'inning July 1. 2010
This Application Becomes Your Building Permit When Approved Paid 5 -- d 1 s -ll Pee& No. 6 72_...
Date V- 2 _ 2, _ < ( B
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372