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� rRx CITY OF PRIOR LAKE Date Rec'd
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HEATING /AIR CONDITIONING /FII2EPLACE PERMIT
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1 Green city I PERMIT NO. a Z ¢,3 4
(Please type or print and sign at bottom) Yet +o Applicant
ADDRESS �j. �} ,/�
J '�/ V ZONING (Deice use)
LEGAL DESCRIPTION (office use only)"
nly) " •
LOT BLOCK ADDITION PID
OWNER
(Name)
v 1: l
(Phone) / ' •
(Address)
1 5 Ct 'Fl .h Poi a % g- f
APPLICANT
(Name) 1 kv. HEATING & AIR INC. hone
(Address) 5182 WEST BROADWAY } .
(Address) CRYSTAL, MN 55_499 '
(, C n (City) (Zip Code)
(Contact Person) ■ U. L t. 4 .6 1 i
(Phone)�
APPLICANT SIGNATURE At 1 1 ,1 ` ;;_/ I I. DATE / h
APPLICANT PLEA, r COMPLETE BELOW
ONEW 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
['Gravity ❑ Hot Water Units and Fireplaces Cannot Encroach
■ echanical 1C ? ❑Radiation into Required Side Yard Setbacks.
►' 4 it Conditioning ` (�/ ❑ Special Devices 1 . Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
❑ ent. System 0 Other Devices
FIREPLACE MAKE AND MODEL Require a Building Permit.
FEE SCHEDULE
Industrial, Commercial & Multi-Famil n
Y 1 /o 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 $ bl�'"�'k Building Permit #
The Minnesota Statutes § 320.148
HEATING PERMIT FEE $ "SURCHARGE," has been changed Ibr one
STATE SURCHARGE $ year effective
$� Jtrh' 1.2010, ut +(il Jugs 30, lltl I.
TOTAL PERMIT FEE $ V d L i 5 The minimum surcharge for a "fixed fee" permit
(Office Use Only)
v is ,SS, beginning July 1, 2014
This Application Becomes Your Building Permit When Approved Paid s -- 2) Recei No. //
Building Official Date S ^ t! t , 1 B
Date Y `
24 hour notice for all inspections (952) 447 -9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372