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(iiiR, CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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2.1.YeP;nk /2y ...
PERMIT NO.
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(Please type or print and sign at bottom) 3.Yellow a fieant
ADDRESS
ZONING(office use)
—7 /�
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER r—^
(Name) / I Yr) TeM4 hl (Phone)
(Address)
APPLICANT /.4,A'-
vv- Q fi/7 gel D
(Name) P�0r /.4 FA'- /4l5 // (Phone) 75
II(Address) r i A sa t Y., .• 4— S3 7
(Address)
(City) (Zip Code)
(Contact Person) Z A jY
(Phone)
APPLICANT SIGNATURE DATE „,,TL---0/1::„-
2442
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION ❑REPLACEMENT 0 ALTERATIONS
FURNAND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants PLEASE NOTE: Air Conditioner
eam
Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
into Required Side Yard Setbacks.
❑Mechanical ❑Radiation
Y6' Conditioning 0 Special Devices Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
ill Vent.System ❑Other Devices
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 $49.50
E'-"--`-a Cost$ BuildingPermit #
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended
until June 30,2013, HEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee”permit is$5.00 TOTAL PERMIT FEE $
I
This Application Becomes Your Building Permit When Approved Paid 5-i .s---0 Rece.. ) o. / S—
r`7 /�
Building Official Date Date.,.� . Z ,, /22
C>7 y
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372