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rRro CITY OF PRIOR LAKE Date Rec'd
E c HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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2 PERMIT NO /�
. Green City 3 _
3. Yellow Applicant ✓ _ V II��JJ D a
(Please type or print and sign at bottom)
ADDRESS i ZONING (office use)
4 1.3qc< ?r i rw w 00a. eeF G-- s
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER [[ ll //�1
(Name) \)OS\ c LI � '�ri Pry b la (Phone) �'I� 47V + 2
(Address) 14 [ Art Dv wood a
APPLICAN t `� 2
(Name) • L is .. it v 11 4 Y `/ (Phone) 51 '` , 3 I J 5.--M
(Address) G lo V 1 1 l I' l 0 n -'" t � n , flr fl 55
(Address) (City) (Zip Code)
(Contact Person) ni hCiSah (Phone) 6951- 4 5 - g' 7
APPLICANT SIGNATURE . _'` ,L i C IP A 1 4 .- • DATE Li/ 443
APPL CANT 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
❑Gravit ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
] fr Conditioning El Special Devices Fireplaces with Box Additions or
Ve nt. System ❑ 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 $49.50
1-;,,,rPl1 Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $ 49 - �b
The minimum surcharge for a STATE SURCHARGE $ ,'
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 'S 4. se
This Application Becomes Your Building Permit When Approved Paid / 5 � Receipt No. 9, 7 i/
Building Official Date Date I/2.) By / i...,:
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372