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yRio CITY OF PRIOR LAKE Date Recd
° - = '� HEATING /AIR CONDITIONING/FIREPLACE PERMIT
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I 4rIMVESd�P I. Pink Pile
2, Green cit PERMIT NO . ��yy
/3 79/
3. Yellow Applicant
/// JJJ 79 licant
(Please type or print an sign at bottom)
ADDRESS ZONING (office use)
, / 4 /q540 - eri.oittari) W a l .
•
•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER r^� �,
(Name),
I �/e(� (Phone)l% � ' j
(Address) / YY5 6 -- Ca W 1
APPLICANT ^�, �/
(Name) �'> & 4 / � d ' Vi Y off-✓
(Phone) 1.5
(/ 4r d O - �1 ' n ,(�,, Wit' ,�... . e za• .�� - •
(Address) d •
/ l (Address) I (City) (Zip Code)
(Contact Person) 6 C i"�'�' (Phone) / a' ' re 7 ` 5
APPLICANT SIGNATURE DATE 7 - i 8' /3
APPLICANT PLEASE COMPLETE BELOW
NEW CONSTRUCTION , REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL t
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
DWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ' W" ❑ H ot Water
�. p a 0 Devices
into Required Side Yard Setbacks.
❑ Mechanical �� ❑ Radiation
g
JAir Conditioning i 3 ' 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 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
f
Estimated Cost $ A 5 Building Permit #
The Minnesota Statutes § 32613.148
HEATING PERMIT FEE $ qq, "SIiRCI IARGE" has been changed for one
Year effective
STATE SURCHARGE $ f t' .50 July 1, 2010, until ,111 ne 30, 2011.
TOTAL PERMIT FEE $ y�0 The minimum surcharge for a "fixed fee" permit
(Office Use Only) is S5, beginning July 1. 2010
This Application Becomes Your Building Permit When Approved Paid Receipt No. yse
Date / % ,� By
Building Official Date // fN .44.,..c,,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372