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4 PRI0 CITY OF PRIOR LAKE Date Rec'd
~ �4 HEATING /AIR CONDITIONING /FIREPLACE PERMIT Z up e I
t
jirNESdc 2. G 1. Pink reen File PERMIT NO . // / 8 0
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
/L/J/ j NI ZONING (office use)
�J i
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) tili /y F 16(5 1 ° 'I A (Phone)Q ✓2 " "
(Address) r t-HO ( • D.1m t I C) Y V NI r V
APPLICANT O ` '' / �j _ Q� Q
(Name) A I A4.� 0 (Phone) "1 r 2 - g 5 O 5 S
(Address) lapin D� I id () ,i • t� `,1' 1 ��1 %�5
LlyidQ, (A J c) . ( ddress) (City) Zip C000de)
(Contact Person) , is'e QQ/ (Phone) ab �) - �l AS U Q J5 ✓
APPLICANT SIGNATURE .......„, ,4 1 ' 4,4 . Li DATE / CX in
APPLICANT PLEASE COMPLETE BELOW
❑NEW 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 into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
[t it Conditioning ❑ Special Devices Fireplaces with Box Additions or
:Went. 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
i ne ivimnesota ouuules 9 .52oi3. 146 - _ - $ Building Permit #
"SURCHARGE" has been changed for one
year effective &TING PERMIT FEE $ l SO
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit \TE SURCHARGE $ UU .J6"'
is I5., beginning July 1, 2010 TAL PERMIT FEE $ 5.50
This Application Becomes Your Building Permit When Approved Paid .-¢. Recei No. G 3 ¢Zd
Date .? Vi / ( By
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