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4 r RI CITY OF PRIOR LAKE Date Recd
�� HEATING /AIR CONDITIONING/FIREPLACE PERMIT
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. 1 Pink File ` / /
PERMIT NO
2. P r een
3. Yellow City /� w Applicant ///
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) CA , vim .. (Phone) l5 —' \r3 lo
(Address) \ \I,V \ UAW> f R •) 'pK C MAr
APPLICANT
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(Name) e5 % i�Vf( ‘41/n k' k ‘ 12 "" + (Phone) k4S\ -- Vo
(Address) W ' N. ' Av fis, .,v.mr ;;V"` v %et-4
(Addr ss) (City) (Zip Code)
(Contact Person) ( ims AN I (Phone) S \ - 'OO \
APPLICANT SIGNATURE 111 DATE ‘0 'Lv \\
w v LICANT 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
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
Mechanical f1/411;" 9-A. ❑ Radiation into Required Side Yard Setbacks.
g �� 0 Devices
DAir Conditioning ? Li Fireplaces with Box Additions or
['Vent. System r Dev ices Cantilevers to the Outside of Buildings
oQ�S'Y'( Qk•�� '` � v�„�� 're 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
The Minnesota Statutes § 326B.148 lost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $ 4 4 .
The minimum surcharge for a STATE SURCHARGE $ .5049
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ T-3 •
This A 'o Becomes Your.Building Permit hen A / roved Paid c> Receipt No. �i% � 3Z
l ill L`� (C - Z - � `/ Date By a�,/
t q, . ' , . Official Date O MAI ,
24 hour notice for all inspections (952) 447 -9850, fax (9 2) 44 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372