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c G CITY OF PRIOR LAKE Date Rec'd
HEATING /AIR CONDITIONING /FIREPLACE PERMIT ,0. ,/. scP I. Pink File
2. Green City PERMIT NO. , 3 / , t f
1 Yellow Applicant
(Please a or print and sign at bottom)
ADDRESS ZONING (office use)
4-*.'t 0 -- D O■-\C- 0 . Sk - Ri •
LEGAL DES I� DESCRIPTION (office use only)
LOT '� `��LoC / .161,,; 4 -' PID 0'5 0/3 0
OWNER C `
vc- a s �
(Name) (Phone) l S Z- S 3 - 6s
(Address) CA. vj
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APPLICANT PYt)� ( �- S -�
(Naxne)_ 7 O � (.L'H L (Phone) c rS Z ,
(Address) 7S p b W GAS k� -� ' 1,,, * "t 1V / L 1
,� I (Are ) (City) (Zip Code)
(Contact Person) J v A - s C ' .,:) l�&._ L (Phone) S c..4-41^-€
APPLICANT SIGNATURE � ■./ L DATE CI 1 `' 1
O
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APPLICANT PLEs�'' COMPLETE BELOW ,
ANEW CONSTRUCTION 1 d REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL E Cl Al & 9 ZS FUEL 6 &LS
FLUE SIZE RETURN OPENINGS INPUT lbw OOCX.) OUTPUT 9C,,boo
TYPE OF SYSTEM HEATING OR POWER PLANT .
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
)?(Mechanical into Required Side Yard Setbacks.
❑ Radiation Fireplaces with Box Additions or
Air Conditioning ❑ Special Devices
0Verrt. System Q 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) 564.50 Residential, AC Only $49.50
Estimated Cost $ Building Permit #
The IVlinnesota Statutes § 32611.148
HEATING PERMIT FEE $ GI • S b "SURCHARGE" has been changed for one
year effective
STATE SURCHARGE $ .50 July 1, 2 010, until Jurie 30, 2011.
TOTAL PERMIT FEE $ rj 4 • 5 o The minimum surcharge for a "tiled fee" permit
(Office Use Only) is Ls; beginning duly 1.2010
This Application Becomes Yo uilding Permit When Approved ID Receipt Nc1.1 D' `
7 ) „t< k° . \ \ , Date By
Building OKia Date `C .\\ f
!!! 64 h •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 - 4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372