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o � riuo CITY OF PRIOR LAKE Date Recd t.._
HEATING /AIR CONDITIONING/FIREPLACE PERMIT
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d fNNESD�P 1. Pink File PERMIT NO . l ti ��
2. Green City / y 9 lG'
3. Yellow Applicant
(Please type or print and sign at bottom)
AP_WE S ZONING (office use)
W Or dil 1 WM .5
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWN E 11 V (Phone) 01 7 5(.
(Address) L (clidu fidqc 11 Pt I or U.° I — —
(NPLICANT 1 � S Y / �' /a�, � l/I 1 ( 1'7C (Phone ( f 1.. E39
. ) 1t... airr P 5 ( - 75 (Address) _ ���� ��� l'"- /
(Aaaress) ✓ (City) (Zip Code)
till r
(Contact Person) ' 0 ■ (Phone)
APPLICANT SIGNATURE 4 111 )
1 Y a4 v DATE 'J -a1-r5
APPLICA T PLEASE COMPLETE BELOW
:NEW CONSTRUCTION RREPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL ea li Y y aq A- TJJY,0 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
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑
M echanical ❑ Radiation Fireplaces with Box Additions or
IffAir Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑Vent. System ❑ Other Devices
Require a Building Permit.
1
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
1 llc 1V1n1L3SUta JLiUUUL S tj JGVD.140 - ' ) S t $ Building Permit #,
"SURCHARGE" has been changed for one
year effective
Jve [EATING PERMIT FEE $ - . "'•
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TATE SURCHARGE $ • 00 .50
is K, beginning July 1, 2010 OTAL PERMIT FEE $ .
This Application Becomes Your Building Permit When Approved Paid 4 t / ? /p Receip�N 7s _
Date J By !o y�
Buildintr Official Date . L 03
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372