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CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
�IlV]VESOS�
I.Pink File
2.Green city PERMIT NO. /G . 7...4.../f
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
ZONING(office use)
VN 5 °\^� c cvr f , q )t.
Lc 10
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER -- ( f
(Name) 4k f"..kr\ J \ fir` ` S 0 Y1 (Phone) `p I ''.%CI-Q.3`r
(Address) \\A S CA �4'r`r o 41 ,T` Lc' - ,V.....
APPLICA '
N
(Name) V IN 1 r (Phone) CA S A'L14 1 - p \ 1/4-4f
(Address) \ c\i \ L orNA . cc Q t\ ec\,(, S -71-a_
(Address) (City) , (Zip Code)
(Contact Person) (Phone) c a i"\\'1 -_ 1
APPLICANT SIGNAT411M
DATE 3 ) l``o
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION REPLACEMENTI [I ALTERATIONS
FURNACE MAKE AND MODEL ` ,t----j c...,-‘"It C1.- V �D '�V a 1 FUEL N ovi
FLUE SIZE RETURN OPENINGS INPUT 'Q O- OUTPUT NI,p 1 W
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air PlantsPLEASE NOTE: Air Conditioner
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
0 Mechanical ❑Radiation into Required Side Yard Setbacks.
❑Air Conditioning 0 Special Devices Fireplaces with Box Additions or
❑Vent.System 0 Other Devices Cantilevers to the Outside of Buildings
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 $49.50
Estimated Cost$ Building Permit #
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended HEATING PERMIT FEE $ u S
until June 30,2013, STATE SURCHARGE $ 150
The minimum surcharge for a TOTAL PERMIT FEE $ S 0 Sd
"fixed fee"permit is$5.00
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Building Official Date Date'30 ByNit-,_,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372