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454:50
CITY OF PRIOR LAKE Date Rec'd
(ci,Rf .o
e HEATING/AIR CONDITIONING/FIREPLACE PERMIT e/
i-, 'max
V �i
C�NESD: 1. Pink Fite
2.Green City PERMIT NO. 857)3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
IL 3 roe> traiI se
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
O(Name) C,reo
dO
(Address) jLJ hnsor (Phone) lv2- 1-41- 21LD
maple trail S6
(Name)
APPLICANT of in! ( I . man S 1 I',_ (Phone) /_
V _Y 7 II
(Address) 1 1 / TM r. i / ei g I I 1781PACII
(Address) (City) r, (Zip Code)
(Contact Person) jail\r :OM
O 1Q.11 (Phone) de' ,i,
APPLICANT SIGNATURE O DATE7 J1 1
'
APPLICANT PLEA E COMPLETE BELOW
❑NEW CONSTRUCTION// /+/� REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL �rll�(.r! 17i / 0 V7Q3 FUEL
FLUE SIZE RETURN OPENIN INPUT OUTPUT 10/
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
Gravity ❑Hot Water into Required Side Yard Setbacks.
Mechanical /Ma1tif ❑Radiation
Fireplaces with Box Additions or
'r Conditioning u� 0 Special Devices p
['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
,nc tviuluvSuut Jtatutes 9 3cob.140 $ Building Permit #
"SURCHARGE"has been changed for one
year effective
July 1,2010,until June 30,2011. tTING PERMIT FEE $
The minimum surcharge for a"fixed fee"permit cTE SURCHARGE $ .50
is$5.beginning July 1,2010 CAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid5-9_sv ,t No. &3/6k,
Date �'// /// :y
Building Official Date G�
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 1
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372