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pRI CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
I
air 1 �x
4-11IVNESO �s� 2. Green City PERMIT NO. /3 .., U 7 / ti.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
61 Nor \odY_ Cars S'E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER. �/1 O C
(Name) OW CJ S li.- `'\ �- wO ICS (Phone) 303 - L- 2 - 1-Cf 5 ° I 7
(Address) % CY OIL. A 1r1rGGI0� co goon
APPLICANT ' L _ _
(Name) TDuirnSV1kie., ` - kerkk`Ac `�C AC (Phone) Of 3v1 - (�C1.Li "6OO5
(Address) 34.� W. &ky \l 5 l l V y - I2r) 6 u.m S l ls_ GS 331
(Address) (City) G (Zip Code)
S (Contact Person) hc « (Phone) 635. - Nt4 -000J 0 p}-• 2
APPLICANT SIGNATURE St. ..i1. 1...ei Si DATE U -31 "/ 3
1
APPLICANT PLEE COMPLETE BELOW
C ❑NEW CONSTRUCTION Ail REPLACEMENT ❑ ALTERATIONS
F A AKE AND MODEL Pj't- 6 a 1- 11 3 }60IA 030 FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water
❑ Mechanical ❑ Radiation into Required Side Yard Setbacks.
❑Air Conditioning 111 Special Devices Fireplaces with Box Additions or
['Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIRE21 ACE MAKEZniD *M L ^ �J�`( P )f' C
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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
HEATING PERMIT FEE $ ' . sb "SURCHARGE" has been extended
STATE SURCHARGE $ IIPOP until June 30, 2013,
TOTAL PERMIT FEE $ 1j The minimum surcharge for a
(Office Use Only) "fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid $ t Receipt No. j Q 1_ 2 .,
•
Date q/3 /3 By
Building Official Date ,/ 1
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372