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p R to CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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4 I. P Filc
' 2. G n F c t >. PERMIT NO /L_ /'4 3
3. Yellow Applicant
(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) /V- V'"� N4 (Phone) �4) - z/L/(J 3 7?9
mu � 8 377
(Address) s� �2- to O g
(Address) (City) (Zip Code)
Phone 959 � yv - 3 -7 �
(Contact Person) 4.- / � (Phone) /`�
APPLICANT SIGNATURE ,7 ' ,, ,, _ / w "'� DATE V__d_e_28
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
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
❑Vent. System ❑Ocher 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, Addi)'o n terations $49.50
Residential, Heating Only (New Construction) $64.50 l .. Residential, AC Only $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes * 326(3.148
"SURCHARGE" has been changed For one
HEATING PERMIT FEE $ year effeetive
STATE SURCHARGE $ .50 JalV 1, 2(110, until June 30, 201L
TOTAL PERMIT FEE $ The minimum surcharge for a "filed fee' permit
(Office Use Only) is ` 5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid J-0 s-6 Receipt No. 6, O
Building Official Date Date 7 /�J /1L By ' � —
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372