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F rRlo CITY OF PRIOR LAKE Date Rec'd
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A HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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l Pink File
2 Green City PERMIT NO . �
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3. Yellow Applicant / J
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT,
(Name),. F vo-f it 1- p� V (Phone) 5� -/ L�� 3 779
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1� & iv' La, 3"7)
(Address) i C� (D 0 g
(Address) (City) (Zip Code)
(Contact Person) / / 4 (Phone) 9 l (//)- .5 7'
APPLICANT SIGNATURE % _i / / "'� DATE GhSAL______
APPLICANT PLEASE COMPLETE BELOW
[]NEW CONSTRUCTION REPLACEMENT El 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 into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
❑Air Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑Vent. System ❑ Other Devices
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 i Residential, AC Only $49.50
Estimated Cost $ Building Permit #
The Minnesota StatutesS 32611.148
"Si RCIIARGE" has been changed Ibr one
HEATING PERMIT FEE $ year effective
STATE SURCHARGE $ .50 Jul, 1, 2010, until .rune 30, 2011.
TOTAL PERMIT FEE $ t' he minimum surcharge for a "fixed fee" permit
is Isif.4 beginning July 1, 2010
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid - ` o Receipt No. • w O
Date 4 By
Building Official Date /[7 �•r �•(�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372