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1 ?Rio CITY OF PRIOR LAKE Date Rec'd
�\• HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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1. Green C Fiit
2. /3 - D 7„g,
,'iN�£y,S� Grei,y PERMIT NO. (/
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / � M) ZONING (office usc)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) J , n t a" to i4 y ! � d � (Phone) (. /a • ! ° d A Sr
(Address) J 6 j q &mitKJ)i) i It 6-
(NamI) r � !' . (Phone) (o� L ?.1/, x 6 67
(Name) L:�
(Address) ' I r t ' L( ?} 11 I Q
(Address) (City) (Zip Code)
(Contact Person) - _ ',----, _....I (Phone)
APPLICANT SIGNATURE DATE j 1
I''
APPLICANT PL R E COMPLETE BELOW
DNEW CONS RUCTION REPLACEMENT ❑ TIONSS i
FURNACE MAKE AND MODEL na *JC ��1OOLD- -- (177, GiiteP i1 - 704)a 4 1� / / ��FUUUEEL Nt' eCl,)
FLUE SIZE 1)114 1 ML, RETURN OPENINGS 4�VS'j jt� INPUT C IO OUTPUT SY44
TYPE OF SYSTEM p� HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
[IWarni Air Plants Ihr'te• ['Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
echanCondical i y ❑ Radiation ❑Special Devices Fireplaces with Box Additions or
Air itoning��lt Cantilevers to the Outside of Buildings
❑Vent. System ❑ Other Devices a
Require a Buildin 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
Petiroatpri Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended HEATING PERMIT FEE 4q
until Lune 30, '2013,
The minimum surcharge fora STATE SURCHARGE $ 6 - .090
"fixed fee" permit is $5.40 TOTAL PERMIT FEE $ <II, �D
This Application Becomes Your Building Permit When Approved Paid Receipt No. j_ 93a
/�
Date r/7 /'' 7 A3 By � Buiidine Official • Date ► '�-�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372