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o� VRIO CITY OF PRIOR LAKE Date Rec'd
,, , e HEATING /AIR CONDITIONING/FIREPLACE
1_, Li .., /
CE PERMIT
/vEse 1. Pink File r
2. Green City PERMIT NO./L_ 70
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(NWmTER Z w _ t 5S-C23 (Phone) (.1:51 — f /5a62
(Address) I C"� ': 1., Q \lkiL) i PrlcrL L L k j. 11 � 5 7
1
APPLICANT ` 1 -t i 1 < �, I
(Name) C� 1 U\ tom_ \`- ecur k Cr - 4"�i)YY■ (Phone) etS�- 49 —( i l `p
(Address) [ 0 0 F C 'o(QC L ) � �r" J 3or ou- I ( al 1 0 SS S ,_.�
(Address) l (City 1 (Zip Code)
(Contact Person) ) = —(
- _ (Phone) Jd ` ( 6 1 D- l q - L,
APPLICANT SIGNATURE / DATE /
AP P ICANT PLEASE COMPLETE BE W
[NEW CONSTRUCTION ❑ REPLACEMENT ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT i
❑warm Air Plants PLEASE NOTE: Air Conditioner
❑ S team Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
❑ Mechanical El Radiation into Required Side Yard Setbacks.
❑Air Conditioning ❑Special Devices Fireplaces with Box Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
) n Require a Building Permit.
FIREPLACE MAKE AND MODEL 7)QZy C
5(0`1Oi -- 1i -
FEE SCHEDULE
Industrial, Commercial & Multi- Family 1% of job cost esidential, Gas Fir lace $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 $ L ig • ` 0 "S11 RCHARGG" has been changed for one,
STATE SURCHARGE $ r 07.----)'.4t year effective
TOTAL PERMIT FEE $ r) `:
(Office Use Only) ✓4-' The minimum surcharge fora "fixed fee" permit
is `- f;, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5v �1 Receipt No.
4,6S
Building Official Date Date �7� / / By ///.
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372