HomeMy WebLinkAboutGas Line Permit 12. 1262 J
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. pR - CITY OF PRIOR LAKE Date Rec'd
,� .� f • HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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411 NivEsd st ' 2: c en Cit,, PERMIT NO. ,r _ Z
3. Yellow Applicant Y
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LI LOO Le LOraS S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER °4F'
(Name) , 4l S ° f t 1 - - -e _ . 3 -v\-t (Phone) q J L i la — 0 7 8 i t
(Address) Li0L LtAS 5
(Name)
M p' l�M 6M ( L4 �Z `L. (Phone) q5C� % y J y�`4
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(Address) 1 LI 1 ."-- ) i 3
w""" S SS 9
(Address) (City) (City) (Zip Code)
(Contact Person) ' t S v 1 L ICS (Phone) 9 �� 9 L ) L i l l
APPLICANT SIGNATURE DATE /
APPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
['Vent. System `❑ Other Devices 0 pi.t Li f.1 {... Cantilevers to the Outside of Buildings
•
cur 00l-dNf Q�(• )) Require a Building Permit.
FIREPLACE MAKE AND MODEL 9
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 $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes * 32613.148
HEATING PERMIT FEE $ y9. "St RCI lA has been changed for one
year effective
STATE SURCHARGE $ .50 JtrIY 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ v 1 •°,4D The minimum surcharge for a "liscd fee" permit
(Office Use Only) is 5S, begi nning July 1.21)10
This Application Becomes Your Building Permit When Approved Paid g$ 3 Receipt No. i 7
Building Official Date Date /, /3 / /2_ By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372