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CITY OF PRIOR LAKE Date Recd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
44 > Qtr• 2 PERMIT NO. /3 __iC_ 4
Maw rite ar print and sign at hoops)
I ADDRESS ZONING office nee)
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LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(N f 67):-/-:-/-41---- (Phone) a/2 - J7E2S= `,2/.J�
(Address) � �z/ (�4 r( � ��¢,e !L 4,/1 P. r.' — .
APPLICANT .;) -y-
(Phone) '- 1Ge-
I „am.) G r ....--
(Address)
—
(Address) 19/41 s— (;:;-,4•41-6,&-',.:(4<' Com,-, . Ln.3052riA.Y4 SS-7i4• 6'
)(Address) (City) (Zip Code)
(Contact Person) 22)..0.0--1 t 6'7hone) 1 ` >2/-/�/'J s
APPLICANT SIGNATURE --------- ------ P
'" DATE /a -
APPLICANT PLE E COMPLETE BELOW •
ANEW CONSTRUCTION { PLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
OWarm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
DGravity 0 Hot Water into Required Side Yard Setbacks.
o Mechanical 0 Radiation Fireplaces with Box Additions or
OAir Conditioning t�ilrer "it Special Devices Cantilevers to the Outside of Buildings
event.System 0 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 $49.50
•
Estimated Cost$ dfifir-.°6Building Permit It
The Minnesota Statutes*326111411
-1/.9,' �7 "SURCHARGE"has been changed for one
HEATING PE ItRIIT FEE $ year effective
STATE SURCHARGE $ ,gyp .50 July t,2010.until June 30,2011.
TOTAL PERMIT FEE $ ,cfpv..fl& The minimum surcharge for a"tiled fee"permit
(Office Use ) is,beginning July t.2010
This Application Becomes Your Building Permit When Approved -Paid '41"4/-�1) Receipt No. idv a r
Banding Official Date Date 9//043 By .G4v _
24 hour notice for all iaspeetioas(952)4479850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372