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E00%rRtp CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIU eTyJNNEse1.Pink File PERMIT NO. //' ,56
2.Green City /
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I LACIS, U3i 1 IOk --tTh cam)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(OIvaWNE)
R (1a `-X-a l�-ro1
(phone)5---�3-Th-Ciel
(Address) I Co q 2. La I C3 LX L-3
APPLIC T
(Name) 1-1 l3C� j L i CIO (Phone) 31—---tri
(Address)(4 5 W . It-t{ e lap c \J 1 ( Le 55134-
(Address)
54(Address) ' (City) _ '�,3i-- (Zip Code)
(Contact Person) -01-1- (Phone) (►`S.-` -70C 1C
APPLICANT SIGNATURE c.--c-i- DATE 6 [ I
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION btREPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEIQOX r j Cr - 13� v C_C*00 FUEL
FLUE SIZE Lo" RETURN OPENINGS INPUT C.1OiCOO OUTPUT 5,MO
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
.1 Mechanical into Required Side Yard Setbacks.
❑Radiation
r -. Conditioning 0 Special Devices Fireplaces with Box Additions or
•Vent.System 0 Other Devices Cantilevers to the Outside of Buildings
AsiRequire a Building Permit.
�1MAKE AND MODEL�rI cr- a`, ri a�-1- L...,---i-N>)
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 $49.50
Estimated Cost$ Building Permit #
The Minnesota Statutes§326B.148
HEATING PERMIT FEE $ • 5o "SURCHARGE"has been changed for one
_ year effective
STATE SURCHARGE $ .5.° -•r59 July 1,2010,until June 30,2011.
TOTAL PERMIT FEE $5 4 .57 The minimum surcharge for a"fixed fee"permit
(Office Use Only) is 5.5i, eginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid 5i.: .rn 6 R e. t No. f/5
Date // y
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