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a PR/o, CITY OF PRIOR LAKE Date Reed
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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4* I. Pile
2. Preen r a PERMIT NO. /oZ _Om
(Please type or print and sign at bottom) ? Y�lo Applicant
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ADDRESS ZONING (office use)
l r S3 Fr / ( n l r I 6 ±----
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
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pe'r !l ! C l �7[ 4— (Phone) (qs [ - o1- (
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(Address) /6■'SS Pro ntfil ,h 1 r , )E f�PC J�„tc In 1/ 6.,2 3 - 2 .2-
APPLICANT
(Name) ' /4e4 � r � ( ��1 L (Phone) (6S1) o � — ( ?
(Address) , -- " --- A (G fl (re „k L
(Address) . (pity)
v r (Zip Code)
(Contact Person) . l (Phone) ` 6
APPLICANT SIGNATURE AlenWZV /D DATE ti 0" 9 ( 1
APPLICANT PLEA; COMPLETE BELOW :
ENEW CONSTRUCTION 1311 REPIliCEMENT El ALTERATIONS
FURNACE MAKE AND MODEL O W t k 6 4 2 , 4 , 2 ,2- X e ,2 FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
[Warm Air Plants ❑ Steam
Gravity ❑Hot Water Units and Fireplaces Cannot Encroach
Mal! Mechanical ❑Radiation into Required Side Yard Setbacks.
[Air Conditioning 0 Special Devices Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
❑Vent. System ❑Other Devices
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
Estimated Cost $ Building Permit #
The Minnesota Statutes *3268,145
HEATING PERMIT FEE $ "SURC1- IARGF" has been changed for one
year effective
STATE SURCHARGE $ .50 July 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ , ��1_ ca The minimum surcharge for a 'fixed fee" permit
(Office Use Only) is S;, beginning July 1.2 {i 10
This Application Becomes Your Building Permit When Approved Paid ,37./. yA Receipt No. b /� p'
� U 7Q
Building Official Date Date she h), By 1,1.,. L/
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372