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1),,, CITY OF PRIOR LAKE Date Rec'd
• � e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
N ,,, 6. L `'/ , Z
0 n
- l1Vt Ese I. pink File PERMIT NO . -� /� �f
' 2. Green City / J n y� L-�
I T 3. Yello�� Applicant eG...�� (e,0*--
e/ V
(Please type or print and sign at bottom)
ADDRESS �� Cq-( nd (e � tlo ` ZONING (office use) e....
in A)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER f (� r , c
(Name) i _ _ id . k e (Phone9S2 Y 7 S — 3 Y G 5
(Address) /&( - ‚ LA.
APPLICANT
(Name) , 1." (Phone)
ansai - - . -
(Address) 130 Plymouth Avenue North
Mtnneapvii5, MN55411 X445
Q 12 -$24 tN ( City) tes) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE PAInliff I •ATE " Co 6.--4' 6Z,
APPLICA `" PLEA E COMPLETE BELOW
A ❑NEW CONSTRUCT REPLACEMENT ❑ ALTERATIONS
IDT�ACE MAKE AND MODEL yd Acti FUEL.�1e (
l
FLUE SIZE RETURN OPENINGS INPUT c--, ' 6549 " 0 OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
DWarm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical ❑Radiation into Required Side Yard Setbacks.
N'Air Conditionin g ❑Special Devices Fireplaces with Box Additions or
• ent. 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 $ - 3 - 7 0 1 Building Permit #
The Minnesota Statutes § 32613.148
HEATING PERMIT FEE $ T (• S Q "5 R(11 \ has been changed for one
year efTcctive
STATE SURCHARGE $ 57. , :#9 July 1, 2010, until .June 30. 2011.
TOTAL PERMIT FEE $ s-y. Th minimum surcharge for a "fixed fee" permit
(Office Use Only) So is .5, beginning .1111y 1.20111
This Application Becomes Your Building Permit When Approved Paid es - 4 / S � Rec ' No. v( 7
/ / 3
Date • L 1, /7i (c' (� C
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