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PRI O CITY OF PRIOR LAKE D ate Rec'd
, , HEATING /AIR CONDITIONING /FIREPLACE PERMIT ' 9/. 50
x
�,..... cP ,. Pink File City PERMIT NO . °
3 . Green �� �� ���
3. Green Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
r 5 Z1 Le 4vee iti oaks frcu 1 S E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) Aga' V i ± . / . i II U' (Phone) 56'3 g" (0 I C
(Address) l rz) Le Civ -!'-J bays i 1 S "1=..
APPLICANT 171-0D-4/ r _
(Name) V U � ' +1 v 3( ÷ k (Phone) 1 43/ -- t-38 -0e /
(Address) 9 I V Al 0 A cf t / ." % r 14 Jig ir
(Address) ( ity) (Zip Code)
�
(Contact Person) _ L� A .' ,A (Phone) test- Lf 37 - sU ` o,
APPLICANT SIGNATURE 1. 11 Al,_ Ai_ I DATE 7/1 CV / 3
APPLICANT PLEA E COMPLETE BELOW
['NEW CONSTRUCTION Z REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL L ?Q Y7 h/11 f `7 S Ij go FUEL fit= �
W /
FLUE SIZE RETURN OPENINGS INPUT 30D00 OUTPUT [ '/ 2OO
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑ Gravity ❑ Hot Water
21 Mechanical ❑ Radiation into Required Side Yard Setbacks.
Air 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) $64.50 Residential, AC Only $49.50
The Minnesota Statutes § 326B.148 ` ost $ 47'36 Building Permit #
"SURCHARGE" has been extended
until June 30, 2013,
HEATING PERMIT FEE $ ° 5�
The minimum surcharge for a STATE SURCHARGE $ / '
"fixed fee" permit is $5.00 COTAL PERMIT FEE $ 51, SO
This Application Becomes Your Building Permit When Approved Paid s, 6 3v Receipt No. /; 71
Date 7 / 7 / / 3 By
Buildine Official Date /�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372