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^ l e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
Y `l am
drIN sd o. 1. " "k File PERMIT NO.
3 . Y eIIo Ci pl ! �C
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1'(p aLl Cr RR 1 14,6€ CANE ) ai.Q.e LA it,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER --g— �y
(Name) V 1 'M R
M , IvE GI (Phone) 3020- O f 5 J So (i y
(Address) / 2 /(p a.(' c fia pi ).4 ) ?tD IZ, LA i 55+37
APPLIC - [
(Name) AMt A *.V 11. T, L X X ll,�imb)' d- P 1 �n (Phone) gSa ( /fig - Wifi /
Address / rd 1r - 5 3
(Address) �� ' 3 � In/ JH� � �
(� (Address) , f (Ci ( / Zi ip p / C / ode)
(Contact Person) 14 Ct -rit, v (a V (Phone) 0 " 1 `17
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
a t PLEASE NOTE: Air Conditioner
DWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity S - ✓e El Water into Required Side Yard Setbacks.
El Mechanical
ter ❑ Radiation
DAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
Went. 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 $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
HEATING PERMIT FEE $ .1 '5' "Sl) IARGye has been changed lo one
year effective
STATE SURCHARGE $ 51. 0 a d uly 1, 2010, until .lime 30, 2fii
TOTAL PERMIT FEE $ 'ir „ S-i The minimum surcharge for a "fixed fee" permit
(Office Use Only)
is:if, beginning duly 1.2010
This Application Becomes Your Building Permit When Approved Paid 54 , s - ) Receipt No. ea J - 2 )
Date ei I By
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