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PRIO CITY OF PRIOR LAKE Date Reed
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
4'NNEs01.' '. Pig He PERMIT NO.
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2. Green City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER %� Q LSE � �
(Name) L iebn ok S � � (Phone) J 62.- 'I 2- / l g^
(Address) ,4%n
APPLICANT
(Name) r r1 0 a 4 (Phone) 2- w 2- gJ t 0
(Address) l t ' • Ar■ d'Dt< j < z> _ / - 2 2
(Address) (City) (Zip Code)
(Contact Person) - " (Phone) g(C:2- 4/4/ 7. '// 0
APPLICANT SIGNATURE 114M1,...4 V � DATE � , ( f / - 1
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION REPLACEMENT ❑ ALTERATIONS
URNAC / AKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
arm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
EGravit ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning 1=1 Special Devices Fireplaces with Box Additions or
DVent. System I=1 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 lost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, G
The minimum surcharge for a HEATING PERMIT FEE $ 4 l �
"fixed fee" permit is $5.00 STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
This Ap s ' . °
1 i t , Becomes Your Building Permit When Approved Paid 4 c U Receipt No. 4 r %�lJ6
�l Date B `t
t ui . e Official Date (I 1 Y AO A
1
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372