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o P ItiO� CITY OF PRIOR LAKE Date Rec'd
, , HEATING/AIR CONDITIONING/FIREPLACE PERMIT
I..NEsoo t. Pink File
2. Green City PERMIT NO. // 0/5y
3.Yellow Applicant •
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
ILkYib 0ov-e km-
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER � n /� -7� 4'�
(Name) a `e- + (Phone) (0/� _ / /0 — //
(Address) I LIT?0 Nike QovAlice. I Pi( / _, KO V �5s7
APPLICANT
(Name) LI t 0 l-L)'t/19 ReC(44-P7-1 t"'. 1. k-C_ (Phone) q9 -Lig.) ?c)-7(p
(Address) 1 ®D e t(Q {Cc d U 'V l . Y7 OCU 1 / WIN l 1 .J 5 3 S---- --
(Address) /(City) („(Zip Code)
(Contact Person) A A.` �., - Phone) l��_ �g `` ��
APPLICANT SIGNATURE -------- -''" DATE ,3 /
PPLICANT PLEASE COMPLETE BELOW.
❑NEW CONSTRUCTION ❑REPLACEMENT [ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants ❑Steam Units and Fireplaces Cannot Encroach
['Gravity 0 Hot Water into Required Side Yard Setbacks.
0 Mechanical ❑Radiation
['Air Conditioning 0 Special Devices Fireplaces with Box Additions or
❑Vent.System 0 Other Devices Cantilevers to the Outside of Buildings
� �r,� Require a Building Permit.
�^^ f
FIREPLACE MAKE AND MODEL l4eut 4 6)10 �'SaMC--I3UI 3
FEE SCHEDULE _._-„-
Industrial,Commercial&Multi-Family 1%of job cost ( Residential,Gas Fireplace J) $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 $49.50
Estimated Cost$ Building Permit #
/ �� The Minnesota Statutes§326B.148
4
HEATING PERMIT FEE $ 'r "SURCI-IARGL"has been changed for one
STATE SURCHARGE $ J, OLD At year effective
TOTAL PERMIT FEE $ -,s0 The minimum surcharge for a"fixed fee"permit
(Office Use Only) is i.Z,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid 5--i 5-0 Rec No.&2/4
Dates' /4. //
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