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4 rRro CITY OF PRIOR LAKE Date Reed
o R� HEATING /AIR CONDITIONING/FIREPLACE PERMIT /0, 3/, Q..
V '4NivEScio- . Fink Flk PERMIT NO/2, , /31
3 . YeIl City J
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 3'155 5 f t- tWO v' ei le ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Name)
APPLICANT 6,_/,� l (Phone) CC/ /e (e9 / q3
(Address) /b °3 ( n(6,/ a L 6
• • dress) n (City) (Zip Code)
(Contact Person) ...-e' / 4 4. 0 P' , (Phone)
APPLICANT SIGNA • Al,...- l,...- /0 DATE /..
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL jik„,f• ' UAA FUEL
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 ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
DAir Conditioning ❑ 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 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) 564.50 Residential, AC Only $49.50
The Minnesota Statutes § 326B.148 Cost $ Building Permit #
"SURCHARGE" has been extended —�
until June 30, 2013, HEATING PERMIT FEE $ A A/11. , v
The minimum surcharge for a STATE SURCHARGE $ .1 i%
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ Ma
This Application Becomes Your Building Permit When Approved Paid, L rJ) Re ,t No / 9 �/- /
Date /0 7 ( I •L B N Y, y 5l
Bufldine Official Date ■ .
24 hour notice for all inspections (952) 447-9850, fax (952) 447 - 4245 I
4646 Dakota Street S.E., Prior Lake, Minnesota 55372