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�e RIO CITY OF PRIOR LAKE Date Rec'd
/ .. ;:.,C
HEATING /AIR CONDITIONING /FIREPLACE PERMIT ,; -,
'trjANESO 'cP 1. Pink File
2. Green City PERMIT NO . // i 0
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
m- I 1sam s s ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Naa W • . I • I� (Phone) q52 -
31 -- 1(51
(Address) 34 &I6 61 S vv
APPLICANT
(Name) J*CVt}'J1 - (Phone) ta9/
(Addess) / 0 VOW ! + / / 1 V ! t S ' f� 1 • is 91 •
dd ress) (City) (Zip Code)
(Contact Person) JOJY\ , II Ill Alt A (Phone)
APPLICANT SIGNATURE / I 1►A � • •�•- DATE „ •
V
APPLICANT PL ASE COMPLETE BELOW
❑NEW CONSTRUCTI IN ■I REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL Ate 1, 1 FUEL
FLUE SIZE RETURN OPENINGS INPUT 101000 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.
9S\4 echanical 0 Radiation Fireplaces with Box Additions or
] it Conditioning ❑ Special Devices
OVent. System 0 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
ost $ Building Permit #
The Minnesota Statutes § 32613.148
"SURCHARGE" has been changed for one )EATING PERMIT FEE $
year effective
July 1, 2010, until June 30, Nil 1. ;TATE SURCHARGE $ .50
The minimum surcharge for a "fixed fee" permit i OTAL PERMIT FEE $
is S5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid ���-0 R eipt No. /_ j O 7/
Building Official Date Da /4 ` /'
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372