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, � Date Recd
l CITY OF PRIOR LAKE
(j R/044 INNESD�
- HEATING /AIR CONDITIONING /FIREPLACE PERMIT
2 1. Pink Gre en File Ci ty PERMIT NO. a_ / � l
.
3. Yellow Applicant
(Please type or print and sign at bottom)
bo y y� ttom) �' I l ZONING (office use)
ADDRESS Lt 11uLa -te1 r a I rct.t L N vv
LEGAL DESCRIPTION (office use only)
PID
LOT BLOCK ADDITION " j C�
OWNER C �1� � � 5 C� �a V� J� (Phone) 32 L I L t � _J
(Name)
, . w . L, \\
(Address) 3(.1 Li 1 G i In uca+cc 1 rtu
APPLICANT -
(Name) (Phone) qS?7L7 1000
J
SS ' 61
(Address) (�L� W \U 13 ewrnsv1 1 e, (Address) 10 / (Ci (Zip Code)
(� p
(Contact Person) \- OA (Phone) 0 3 C 1 - — 100 0
APPLICANT SIGNATURE ic1.t DATE / 2 9
APPLICANT PL • .E COMPLETE BELOW
ONEW CONSTRUCTION 'a ' EPLACEMENT O 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 into Required Side Yard Setbacks.
, ❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
it Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
]Vent. System ❑ Other Devices Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE $49.50
Industrial, Commercial & Multi Family 1% of job cost Residential, Gas Fireplace
$49.50 minimum $49.50
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only
The Minnesota Statutes § 326B.148
,ost $ Building Permit #
"SURCHARGE" has been extended 5 until June 30, 2013, HEATING PERMIT FEE $ r'
The minimum surcharge for a STATE SURCHARGE $ 7 .0 0
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ 5 . 50
This Application Becomes Your Building Permit When Approved Paid h y £
Rece N .„
4,i4p f
Building Official Date Date 74 Iii By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372