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CITY OF PRIOR LAKE Date Rec'd
° �' HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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' Gre r'e PERMIT NO. /2 `
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3 Yellow Applicant v'
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS
.e.e6 GreeA, L
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) 0 / f 1 1�!' e 0. — � „/' ( Phone) 9, / ll�� vw 700
(Address) 3e 071.0. ..• , h13 (.,4
(Nam ( / 6 ( �i�? S�?'l gS 7 l 1 '`° ` ' —01 c)C )
(Name) ( ��ti�_ (Phone)
(Address - r. Al ,” ?.r/ // ! 1 . _ i " it ' (94 n -A.. ... i . / c 7/0
(A. • _. (City) (Zip Code)
(Contact Person) ■ I /i
(Phone) 9. l i2 0 - `"`3 e
APPLICANT SIGNATURE VAIIV` -
DATE //—
A ' PLICANT PLEASE COMPLETE BE.
:NEW CONSTRUCTION ❑ REPLACEMENT ALTERATIONS
FURNACE MAKE AND MODEL 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 0 Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation Fireplaces with Box Additions or
❑Air Conditioning ❑ Special Devices Cantilevers to the Outside of Buildings
❑Vent. System _ ❑ Other Devices Require a Building Permit.
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FIREPLACE MAKE AND MODEL v EL/7Z" LU : Ff CPLI1
FEE SCHEDULE 49.50
Industrial, Commercial & Multi - Family 1% of job cost Residential, Gas Fireplace
$49.50 minimum
Residential, Heating & A/C (New Construction) 5149.50 Residential, Additions & Alterations 549.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
r `' Cost $ T . t . " -- - 6/0 Building Permit #
The Minnesota Statutes § 32611148 ''' `J' •
"SURCHARGE" has been changed for one H' ' I. ' ' T FEE $ i fq-
year effective STATE SURCHARGE $ 5 2U
July 1, 2010, until June 30. 2011. TOTAL PERMIT FEE $ .'
The minimum surcharge fora "fixed fee" permit
is SC, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid j
) / L � Receipt No. ' 7 7
` J B /
Building Official Date Date / 2/, i/ y
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 0/V0#
4646 Dakota Street S.E., Prior Lake, Minnesota 55372