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. PRlp CITY OF PRIOR LAKE Date Rec'd
ft a I-IEATING /AIR CONDITIONING/FIREPLACE PERM I T
1
` I Eso'' . Pi6rcenk n File
City PERMIT NO.( z _ - / 3
.
i 3. Yellow Applicant
(Please type or print and sign at bottom) _
ADDRESS ZONING ((Ace use)
' 5/13 (,� 1 1 da 4/2 (- �E;
LEGAL DESCRIPTION (office use only) T
LOT BLOCK ADDITION PID
OWNER
(Name) : _. / Z 95? 0 _-
(Address) YIZ 55 =3 7
APPLICANT ? �^ /�
(Name) � �i�1 C l�.l J ' , e /ii'l,S (Phone) i - 9 j -/ d
(Address) �) • ti �
4� N !� � �� /� I U ` Ol t P�- 5 ; 2
(Address
(City) (Zip code).
(Contact Person) �N/...4,"— (Phone) K D.05—
APPLICANT SIGNATURE __ ■ i - ,_' ■ DATE le "c '/ a
APP CANT 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
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical into Required Side Yard Setbacks.
❑ Radiation Fireplaces with Box Additions or
EtAir Conditioning ❑ Special Devices
❑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 $ p Building Permit #
The Minnesota Statutes § 326E1.148
HEATING PERMIT FEE $ liq 5D "Sl'RCI IARCd has been changed !Drone
year effective
STATE SURCHARGE $ .50 0 July 1, 2010. until June 30, 2011.
TOTAL PERI'IIT FEE $ 5-4 'Z he minimum surcharge for "fixed fcc" permit
(Office Use Only)
t is .w5, beginning July 1.2010
This Ap I I l i : � Becon s Your Building Permit When Approved Paid J Receipt No.4, 3 L
1,1'1 `�f0 9
till Date ij i_ 13y n ^� /
Sat m Date 7 f
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372