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HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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- '^avEso 2. Gree p` °� n Fik Cit PERMIT NO. ///)��
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r' / (Please type or print and sign at bottom) 3. Yellow Applicant /L� /
ADDRESS ZONING (office use)
\0.—iS o CIAA% h.v * L.m.. lv C
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) ■ C-A-1 4-4.....61 ( Phone ) QSZ -`i / - 7 -`40 t •
(Address) "t2 0 C k.la tA_A-- mil_ L
APPLICANT l n t y � �
(Name) 19✓ )4'6 C� '' - (Phone) — (S L" 7 7
(Address) — 7 S Q W et S i het n ' 1' I-- S td,-, I ✓G1tirr AiLN S J sy `1
`'' (A ss) (City) (Zip Code)
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(Contact Person) AOLA.. y (Phone) Sq Q-'
APPLICANT SIGNATURE ,' 4 DATE L7 li Z
APPLICA PLEASE COMPLETE BELOW
DNEW CONSTRUCTION fYi REPLACEMENT El ALTERATIONS
FURNACE MAKE AND MODEL BY'-1O.M. f ° 15 -1 - A-'iZDs b FUEL oCt S
FLUE SIZE RETURN OPENINGS INPUT 5 oo OUTPUT - 77 , t , o 0
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
Mechanical ❑ Radiation into Required Side Yard Setbacks.
NAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
❑Vent. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi - Family I% 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 $ (0, Sgt . p 0 Building Permit #
The Minnesota Statutes § 32613.148
HEATING PERMIT FEE $ s ' y ei. 6 "SURCHARGE" has been changed for one
year ef fecti ve
STATE SURCHARGE $ T. o o -5$ ,July 1, 2010, until ,June 30, 2011.
TOTAL PERMIT FEE $ `'' • 5 O "rile minimum surcharge for a "fixed fee" permit
(Office Use Only) is S5, beginning duly 1.2010
This Application Becomes Your Building Permit When Approved Paid 6z s Rec l No. 6 S ) i
Date 3 0 . l "L B .
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