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.0 PRIp CITY OF PRIOR LAKE Date Rec'd
� e r HEATING /AIR CONDITIONING/FIREPLACE PERMIT
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i t41vES0.t 2. Gte n ty PERMIT NO /2, /� .�
3. Yellow Applicant d
_ (Please type or print and sign at bottom)
ADDRESS ZONING (office use)
f L I 1 o CD ear\Jle.Azood L e..
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Na OWNER �� C O l (Phone) 6 15 "" c /� I-�
(Address) 1 jt I 0 CO ( rY. le t-t)O t9 Lr
APPLICANT
(Name) (Phone)
SEDGWICK HEATING & AIR CONDITIONINGLLC
(Address) 1408 Northland Drive Suite 310
Mend, MN 55120 (City) (Zip Code)
(• . .:1 -.tut
(Contact Person) _� (Phone)
APPLICANT SIGNATURE � ,� 1W DATE " " l 1
APPLIC T PL I 1. RE E� COMPLETE BELOW
❑NEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
[]Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
alAir Conditioning , k n ❑ 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 I% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49 !
Residential, Heating Only (New Construction) $64.50 Residential, AC Only 49. I
Estimated Cost $a() ' ` — Building Permit #
The Minnesota Statutes § 3268.148
HEATING PERMIT FEE $ 1 4 G . 30 "SURCHARGE" has been changed for one
year effective
STATE SURCHARGE $ .50 July 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ 5 0 . 0 C The minimum surcharge for a "filed fee" permit
(Office Use Only) k g, beginning July 1.2010
This Application Becomes Your Building Permit When Approved Paid /(, j D Receipt No. n / / 2. 7,
Date a s -n x... By f I � Buildine Official Date �/
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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