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r RIo CITY OF PRIOR LAKE Date Rec'd
N4 HEATING/AIR CONDITIONING/FIREPLACE PERMIT D.
�P f S
+Lj .54+ 1.Pink File / /� 7
JNNEso 2.Green City PERMIT NO. 1 /�„(�/,�(
3.Yellow Applicant
(Please type orprint and sign at bottom)
ADDRESS ZONING(office use)
- 7I9 +\-turiZOnG1v c P
LEGAL DESCRIPTION(office use only)
LOT BLOCK t/ ADDITION SA 724 k- (/ PID O?jr" 5.-'05/10_
(Name)OWNEjtJfl.$tPhone( ) LO 1 g /�0 "to I
n
(Address) �0��
APPLICANT
(Name) bpl..1Ince Connections inc. (Phone)
(Address) 11350 Chestnut Blvd.
(City)
. ' . "�'�=,� �t ' � (Ci (Zip Code)
(Contact Perso . SAI I , 95 a = -./
G A (Phone)
APPLICANT SIGNATURE insIIMIIMMP" DATE �l S� (w If
IAPPLICANT PL COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENT El ALTERATIONS
FURNACE MAKE AND MODEL Car ries- FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
is Mechanical 0 Radiation Fireplaces with Box Additions or
U it Conditioning 0 Special Devices
❑Vent.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 $49.50
The Minnesota Statutes§326B.148 :;ost$ Building Permit #
"SURCHARGE"has been extended
until June 30,2013, HEATING PERMIT FEE $ la.
The minimum surcharge for a STATE SURCHARGE $
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ / ad
(Office Use Only) 1 IF
This Application Becomes Your Building Permit When Approved I !) Receipt No. IM
NM= By
Building Official Date i
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372