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pR1 CITY OF PRIOR LAKE Date Rec'd
o
e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
i
�, NNEyo 4 ' i. Pink File PERMIT N
i 2. ¥ten city O. /L -tic
j - 3. Yellow Applicant
(Please type or print and sign at bottom)
A DDRESS o ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
•
WNER ,^
( v l P (\c'S at ¶ II el-F)__5 Phone)
(Address) a r
APPLICANT C f c C�
(Name) • • . • _ • ..' ' • • - 1 • • (Phone) .S'2_-- Z- C - C�se
/
an•ar• • •
(Address) 130 Plymouth Avenue North
Minneapolis, MN/55411-3445 (City) (Zip Code)
(Contact Person) (Phone)
812 -824 (r�r�ss) /AI _
APPLICANT SIGNATURE e _/ - _MA, _ 'ATE l (-
APPLICA l ❑NEW CON Ili ► EA COMPLETE BELOW _
ST' CTION REPL C MENT ❑ ALTERATIONS /�'
FURN,QCE MAKE AND MODEL v 4 FUEL 2 Cytils /C,
FLUE SIZE RETURN OPENINGS INPUT ) eeo OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
[Wain Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water
❑ Mechanical ❑ Radiation into Required Side Yard Setbacks.
2fAir 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 $ a:9 Building Permit #
The Ivtinnesota Statutes * 32613.148
(.(5 50 "SURCHARGE" has been changed Ior one
HEATING PERMIT FEE $ ( year effective
STATE SURCHARGE $ .July 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ S (,f. S Ube minimum surcharge for a "fixed fee" permit
(Office Use Only)
J is S5, beginning July I.2010
This Application Becomes Your Building Permit When Approved Paid. ) Receipt No. / sv / i
Date 7I2441— By ( ...z.r..
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