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016/5715 8-7x16.7c
o . t vitro , TY OF PRIOR LAKE Date Rec'd
- HEATING /AIR CONDITIONING/FIREPLACE PERMIT
d'j t. 'Z igt PERMIT NO. / - (I� 3
2. 'Zen City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (Office use)
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LEGAL DESCRIPTION (office use only) /`
LOT BLOCK ADDITION PID
OWNER —�� / � L�
(Name) ° "'y V ` � ` bJ4/ (Phone) / rZ ' ZT U - A.7,6
(Address) /G4/ 4/ // r�C i•- 4 „ - -1-- , 5
APPLICANT / '
(Name) / �� MOW ,� 2-hL (Phone) ('" - ,'z�-- 'T Z_
(Address) / �Z 67'" U L / r pt nc.. moo/ 1.37/ �
•dress) (City) (Zip Code)
/
(Contact Person it, _ (Phone) '72 7c—Oz- - /74 z
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APPLIC • ATURE _ /m
Jr i
I
• ' ' LICANT PLE4SE COMPLETE BELOW
► T CTlONN ] REPLACEMENT El ALTERATIONS
FURNACE MAKE AN ► ' ODEL - v h Cj'G )1"/ I FUEL
FLUE SIZE RETURN OPENINGS INPUT 7- %Al OUTPUT l-re..4.1../
TYPE OF SYSTEM HEATING OR POWER PLANT
[]Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical ❑Radiation into Required Side Yard Setbacks.
!Wit Conditioning 0 Special Devices Fireplaces with Box Additions or
[]Vent. System 0 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 $4930
$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
"SURCHARGE" has been changed for one
HEATING PERMIT FEE $ i' year effective
STATE SURCHARGE _ ,- cell ly 1, 2010, until Junc 30, 2011.
� �
TOTAL PERMIT FEE r ia
Lr � mom surclta fora "fixed fee" permit
(Office Use Only) 7 is Ss, beginning July 1.2010
1
This Application Becomes Your Building Permit When Approved SIMIIIIIK eceipt i o. agall
Date
MIMI
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