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CITY OF PRIOR LAKE Date Rec'd
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I- HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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...... ili tivNEso � , Pi nk File PERMIT NO.
2. Green City id/ 9 ( —. '
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1 ZONING (office use)
3 C i \,1 , ,,1 a,,,,k 6-- \�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER c`\ h `‘,4 (Phone) I/ I Z~ • o 1- 4 -_'I
(Address) (\ g b 0 & 'Li Lk( \
LI V p A ] -' 4 L4 Y a NM
APP
(Name ) A k r p f 1 ' \ L (Phone) •
(Address) `S?1V \' '\S \ 4 A C� A J t. l' r1 Qr. 1 J . '
(Address) (City) (Zip Code)
N , (Contact Person) ( l \\ a�� (Phone) l .D..\-.N.--t - R \ d�
APPLICANT SIGNATURE \ . DATE \\ \k \\
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ALTERATIONS
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FURNACE MAKE AND MODEL � 12 Zr1 U '1 f� U FUEL 11) tl
FLUE SIZE RETURN OPENINGS INPUT U) OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ Special Devices L Fireplaces with Box Additions or
❑ Vent. System Other Devices Tr-AA A S.x, c-3 \ 4 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
The Minnesota Statutes § 326B.148 host $ Building Permit #
"SURCHARGE" has been extended to c1 S j
until June 30, 2013, HEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ s50
"fixed fee" permit is $5.00 FOTAL PERMIT FEE $ St 7
This Application Becomes Your Building Permit When Approved Paid 5 eceipt NI ( 11 i
Date 1 Zti,t1 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