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pRIO CITY OF PRIOR LAKE C/ Date Rec'd
N HEATING /AIR CONDITIONING /FIREPLACE PERMIT
V
NivEse, 1. Pink File PERMIT NOW / � j �'�A
2. Green City �/ / V
3. Yellow Applicant
`
(Please type or print and sign at bottom)
ADDRESS 155 as C) e q, �1.-c,.4 \ E ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNS ii 4 t /, ` p
(Name) 1�PY (Phone) 15 D-• 7 `f O
(Address)1 S as O ►rY1 ? C` Y . Cd k F R l elf Like 1 5'5 5 3 Z �,
APPLICANT RIA � �� (Name) _ l 1,:-.. i. : . (Phone) 714;6 `1 g - 5
(Address) C1 eve - tvJ Nub Sxl .k g ac )r R ip C1 s 1 I ► P 6S
..,,..�� /(�� (Address) (City) (Zip Code)
(Contact Person) i VW1 " 3 AV--e-y (Phone) - 7(0`3 " 54 1 0 1
APPLICANT SIGNATURE , A/ .:1 xis DATE 9/15 / #/
APPLICANT 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
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air 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 $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 • . 1
i uc iviltulwutu JtatutCS y J[,OD. i'Io 1st $ Building Permit # y L \�
"SURCHARGE has been changed for one g / (�'"
year effective l /
July 1, 2010, until June 30, 2011. EATING PERMIT FEE $ , 5 . 0 I
The minimum surcharge for a "fixed fee" permit TATE SURCHARGE $ S._ : — 1' ,
is $,, beginning July 1, 2010 OTAL PERMIT FEE $ _.
`
This Application Becomes Your Building Permit When Approved Paid .
9 c R ce' t No le t2Z ?
Dat
Building Official Date e1 o .5 i I 1 B •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372