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V RIp CITY OF PRIOR LAKE C" Date Reed
N �C HEATING/AIR CONDITIONING/FIREPLACE PERMIT
dj tP 1. nk File
INNES� 2.PiGreen city PERMIT NO.
/
3.Yellow Applicant //
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
kW SI r►11yvwe SE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER Q
(Name) )O ) rVL&S U.S (Phone) 1-2 ' L/"l
r /" 6796,
Ni `' _ tta-cgto- /Ot8?
(Address) , Lit 1 �11 11,VYt[9Y d. 1.'� St Pr Lr' L +e d
6537
APPLICANT A, L
(Name) l ei� Y P� ✓1 TiLC (Phone) -7403--757 ' Zo o'ZOa
(Address)CI 3 O ~V Y eein B t vd a B � R&p N 14s1 O 65'/
J (Address) (City) (Zip Code)
(Contact Person) 'h Avw Vl Z 1` I- din (Phone) *743—757'A2 '
APPLICANT SIGNATURE l/=LA e P7,4r � DATE C5/ill//APPLICANT 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 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation
❑Air Conditioning 0 Special Devices Fireplaces with Box Additions or
OVent.System '`,Other Devices RV Cantilevers to the Outside of Buildings
Vi{,e e(411Require a Building Permit.
FIREPLACE MAKE AND MODEL , M NC
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 $49.50
cost$ Building Permit #
The Minnesota Statutes§326B.148
"SURCHARGE"has been changed for one HEATING PERMIT FEE $ LI q .50
year effectiveilJune
STATE SURCHARGE $ 6: OO -le'
July 1,2010,until June 30,2011.
The minimum surcharge for a"fixed fee"permit COTAL PERMIT FEE $ 5L(,50
is$5,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid /teee eipt No,/ �4 b7)
Date ��� � � � y
Buildine Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372