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. -0 =:1 HEATING /AIR CONDITIONING/FIREPLACE PERMIT
kNi
s eIMvesoi r ` he Fi{ PERMIT NO.
. �;pl ` 43._ Dd
3. 7. Ycllovr Applicant
(Please type or print and sign bottom)
ADDRESS /6,4, le ZONING (office use)
• 16 67 3c) / Li 6 ii/) prior- (V c 3 72
•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OER
(Na iiq ✓ c- (r v / 101 (Phone) •
(Address) / y � f l C err / Q y � L, Pr' 'r / or /� ( r 12 3 7
APPLICANT //
(Name) ! J ( e r J / (c 5 Cc /1/ y -7 . L L c_ (Phone) / 2 - 9 7 1
(Address) /y`17 t A9 /u /9 �iL."
(Address) (City) (Zip Code)
(Contact Person) `'��- (Phone) t. /7 — .5 9 7 "." e,g
APPLICANT SIGNATURE tf DATE e -- /
APPLICANT PLEASE COMPLETE BELOW
ANEW CONSTRUCTION [REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL PW '7 c - i () � my,7_0cie FUEL
FLUE SIZE RETURN OPENINGS INPUT 8g • c' oC OUTPUT 7/ c co
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
❑Air Conditioning El Special Devices Fireplaces with Box Additions or
❑Vent. System ❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi- Family I% 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
Estimated Cost $ Building Permit #
The Minnesota Statutes *326[3.148
HEATING PERMIT FEE $ "SURCFIARGyear effict;v�hanccd for one
STATE SURCHARGE $ .50 July 1. 2010. MI tii June 30.2011.
TOTAL PERMIT FEE $ The minimum surcharge for a "fixed fee" permit
(Office Use Only) is m, beginning July 1.2010
This Application Becomes Your Building Permit When Approved Paid s' / - Receipt No. 3 7s _
Date s 42.1 3 By /
Buntline Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372