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C R i O� -/ CITY OF PRIOR LAKE \ Date Rec'd
e HEATING /AIR CONDITIONING /FIREPLACE PERMIT
x ESO I. Pink File PERMIT NO .
2. Ye Ckp % 3 / /
! 3 3. YelloIIo w Applicant ` l
(Please type or print and sign at bottom)
I ADDRESS ZONING (office use)
: I Uft (01 S fel9LI/V5 CLA S
LEGAL DESCRIPTION (office use only)
0QZ ktO
LOT BLOCK ADDITION 3 t � �a,�d 3 ( - �}fl 0 PID Q53 o$��ja o
OWNER _— l
(Name) lat.l I (-efta VD WS (Phone) c1 5 " 3
(Address) '/ IL 5 - 0.(ei,LEGLD
APPLICAN __ — /V
(Name) (� 1oi-i* l (otvi j fr (P - 210338 3 un
(Address) 4c � L3 ,` Ano f -k �cl. f Tv _ N 1 � t ti1 76v
� s•J
(Address) i, (City) (Zip Code)
. ii t
Q }Corn (Phone) -)
(Contact Person) _ 333 Z !
�i■ _ 1 (Phone
APPLICANT SIGNATU i_ 4., DATE 07- -I
A ' .
• PPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION 'REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODELT(u,t Tu I-060 ¶,OA 3 FUEL Neil 6
FLUE SIZE RETURN OPENINGS INPUT teD Q00 OUTPUT 00 0
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
IC Mechanical ❑ Hot Water into Required Side Yard Setbacks.
❑ Radiation
i� ' it Conditioning ❑ Special Devices Fireplaces with Box Additions or
[Went. 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
Estimated Cost $ Building Permit #
The Minnesota Statutes `s 32613.148
HEATING PERMIT PEE $ ti 1 "StRCI IARGE." has been changed for one
year etTective
STATE SURCHARGE $ .6_11 July 1, 2010, until June 30, 2011.
TOTAL PERMIT FEE $ 6 / �J o The minimum surcharge for a "fixed fee" permit
(Office Use Only) is SS, beginning July I, 21110
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Building Official Date •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372