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O� P RIOT, CITY OF PRIOR LAKE Date Rec'd
4 HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�J4'NESDo
.Pinkn File /�
2.Greey I PERMIT NO. • /43 I
(Please type or print and si 3. Yellow Applicant
gn at bottom)
ADDRESS
< \) S_
k \ t ZONING(office use)
(), v►� sCv-,t ,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER (1-\ `r''
(�
(Name) \ h t CI `,
) � � y �� �MA-. f����`l n (Phone) _f S �~�'"1�-�1� 9
(Address) -5-M f1n Q�� O'� �1 �� L\ .. r c'r `' ` to tk. 1\0 �S
APPLICANT (\,N i\
(Name) �12r^, �, `
` `_ ` (Phone) S a- "`\k� 1 ' y
(Address) 1 v `cam �\ l'�Y� 'L C ,- 1t ^c'\\ -1',
N (Address) (City)
(Contact Person) �� ^-� -j(zip Code)
(Phone) � IS 1 a"1
APPLICANT SIGNATURE Y ),-��� 1 DATE - ,-1 - I
APPLICANT PLEASE COMPLETE BELOW
[NEW CONSTRUCTION REPLACEMENT ❑ALTERATIONS
k...
FURNACE MAKE AND MODEL N�j t..,4 Ck a -\-"IAg avv t FUEL A) u,
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
q
into Required Side Yard Setbacks.
❑Mechanical ❑Radiation
®Air Conditioning 0 Special Devices Fireplaces with Box Additions or
❑Vent.System Ki Other Devices \t,,,r,.. a, k,,,, Cantilevers to the Outside of Buildings
FIREPLACE MAKE AND MODEL Require a Building Permit.
FEE SCHEDULE
Y 1%of job
Industrial,Commercial&Multi-Familcost Residential,Gas Fireplace $49.50
$49.50 minimum
Residential,Heating&A/C(New Construction) $149.50 Residential,Additions&Alterations
Residential,Heating Only(New Construction) $64.50 $49.50
Residential,AC Only $49.50
r_'`'Cost$ Building Permit #
The Minnesota Statutes§326B.148 _
"SURCHARGE"has been extended HEATING PERMIT FEE $
until June 30,2013, STATE SURCHARGE
The minimum surcharge for a $ RIO
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ S
This Application Becomes Your Building Permit When Approved Paid r
eceipt No42//��
Dat . i L� i Y t//
Buildin¢Official Date
L •
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372