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04 rRto� CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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Q. I Pmk File
2 Green c 33`
"t'�N NESO'� Ca) PERMIT NO. �'' I
3 Yellow Apply cant
(Please type or print and sign at bottom)
ADDRES -PA ivG• ' v P. O ZONING (office use)
k/kM Lk.lb bovt, N e -
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone) . 1
(Address)
Pt C041 C-4 1--/8/2-- c IS ,m>z,.. i e''
APPLIC n,_ 1 j f, l
(Name) M JYL P' .k Wl-b 11'l x ti- il•) -4J l r) (Phone) -7 ' -i 5 " 7-2- V1
i i V L
(Address) 1 `.�' 4j.A ,Q I /� 1' 1 l9/ VIA 1 VA IA (- 7 1 ? - 7 1 4 1 4/ /
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(Address) (City) I' (Zip Code)
(Contact Person) I I u Ai (Phone) 1 to y ) - 2- . 5- 71 i
APPLICANT SIGNATURE (\/1WLO1/i/ ' 1. A.. i- -W DATE /2 21- Z(9 f/
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION ❑ REPLACEMENT [. ALTERATIONS
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FURNACE MAKE AND MODEL r y 0011, �- 3'{ n AioN /) 4 ICI n n FUEL N a4'' I &&r
FLUE SIZE a RETURN OPENINGS INPUT Mb , 000 OUTPUT Ci 2.. D D 0
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
DWarm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
DAir Conditioning 0 Special Devices Cantilevers to the Outside of Buildings
❑Vent. System 13 Other Devices
' i d tA-1 i , Require a Building Permit.
I FIREPLACE MAKE AND MODEL .___—I _
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
Cost $ 12SM 6, d t) Building Permit #
The Minnesota Statutes § 32613.148
"SURCHARGE" has been changed for one HEATING PERMIT FEE $ 1 - 2-57 1 '6
year effective STATE SURCHARGE $ .50
July 1, 2010, until June 30, 2011. TOTAL PERMIT FEE $ 1 30 Z
The minimum surcharge fora "fixed fee" permit
is 55, beginnillt�' July i, 2010
This Applica l eco - es7 Building Per it When Approved Paid 159 26 Receipt No:4--1/qt
+ ' `"' ��
i ' ' ! 1 ( 12 Date 1. By I
Bhildi� I t Da .."7 \ . _..i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.13., Prior Lake, Minnesota 55372