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0 . p R1 CITY OF PRIOR LAKE Date Rec'd
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C HEATING /AIR CONDITIONING /FIREPLACE PERMIT / / f 3
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M /n'NESdcP I. Pink File PERMIT NO . / . Green City � _ / / 7
3. Y
3. Yellollo w Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/45(a 0 Dthtl / iZ/L. ,4-1/ s til
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID 26: O? ; 023, 0
OWNER ,--, C ,�
(Name) p gp/ //6/1 4$LfJ /v (Phone)
(Address)
APPLICANT /
(Name) 6_6/A/ fl7 , (Phone) 6/z- z- - 3 6 6 ° 3'/3' "
(Address) 4 h iA q ..c tt2 4r /Az �� 3 7e-- -
(Address) ✓ (City) (Zip Code)
(Contact Person) Ira d A - i it (Phone) _ —3 6 . — 3z)
APPLICANT SIGNATURE ' I S L J "' � DATE �t
APPLICANT PLEASE COMPLETE BELOW
yINEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL r/ / [ FUEL I (jai 5 _
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.
Mechanical ❑ Radiation
a 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 $ Building Permit #
"SURCHARGE" has been extended
until pp
minimum surcharge e,
The mini for a HEATING PERMIT FEE $ 7 `' 5V
mm
"fixed fee" permit is $5.00 STATE SURCHARGE $ ,S _ 0 6
TOTAL PERMIT FEE $ 51_
(Office Use Only)
This Application Becomes Your Building Permit When Approved ai �r - !` s - 0 Recei ? o g
Y r
Building Official Date / / ( // � B i �� y
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372