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; CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
g
Iivivrse 1. Pink Pile 4 PERMIT NO .
2. Green City _67
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
l 9y, V ° C a.. ire Wai
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER y� 1, ( � '` _
(Name)' b h l Pi fi T(„ 1 it I' t, I (Phone) l S 41 - 7 . ? 7
(Address) 1 VO7 - a iy. , e, (4) a y
APPLICANT ,/ �, f d /
(Name) ,. b 1 M 5 / d Ei Y1't j t 4 k. n (Phone) -" g � C5-1437 V 4'5✓�
(Address) / d' Y!
g- /UU r ni GL - a a11 e 6 l i /76 Dm 117_7n, Z o2 /^`)
(Address) City) (Zip Code)
(Contact Person) if 14 6 1 D 5ie, FC- (Phone) 115- — Y ff 2--- y5'3
APPLICANT SIGNATURE 674 DATE 7 ---/!'``
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ►.i REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravit ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical 0 Radiation Fireplaces with Box Additions or
jC Air Conditioning ❑ Special Devices
EVent. 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
"SURCHARGE" has been extended ost $ Building Permit #
until June 30, 2013,
The minimum surcharge for a SEATING PERMIT FEE $ ' ,/ s i .51)
"fixed fee" permit is $5.00 ;TATE SURCHARGE $ , 50 1
TOTAL PERMIT FEE $ 1 • -1)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid \...4 Receipt No. 94 Q'
Buildin¢ Official Date Date 7J 7 43 By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372