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. CITY OF PRIOR LAKE Date Rec'd
: HEATING /AIR CONDITIONING /FIREPLACE PERMIT
x
�/AiNESo'P 1. Pink File pERMIT NO
3. Yellow City / / izal
3. Yellow Applicant r
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
t 4 I HS 01 v\ASC)a5 0)( N
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER Sler Q`,' l / ~� (Name) CXMav -S (Phone) I 'yet)
(Address) `1 k`-Cc lIL " . ) 1 ,4 (1 l,l if'C'i le NE 9r ► Lake 1Yt 'J 6
APPLICANT A
(Name) l._ Q, (' Pn \ nV c:V \L`' (Phone) -1 OS -75L 5
(Address) et - 6ao ae(c w NW ot..U' . js , m w . 5433
(A, dress) r / 1 (City) ler (Zip -SOY/
(Contact Person) . AV\ Z-+ VV S (Phone) - 7(03- { S4k
l
APPLICANT SIGNATURE . . . et[i, >i / , DATE ` e) /�CV /1 /
1 A 6(2 372 - ?727
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ,REPLACEMENT ❑ ALTERATIONS '
FURNACE MAKE AND MODEL Pa l c r 6 1 5 1 1 r 1 e o` w - l t FUEL , 'Y �r �C�S
FLUE SIZE RETURN OPENINGS INPUT 3'1) C OUTPUT 761 G
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.
7 g Mechanical ❑ Radiation
Air Conditioning El Special Devices Fireplaces with Box Additions or
['Vent. System ['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
Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one HEATING PERMIT FEE $ y9. ,O
year effective STATE S $ t � .$$'
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 6 Li
is S5, beginning Jul 1, 2010
This Application Becomes Your Building Permit When Approved Paid 540-6 Rec t No. / /
Date/ �. _ i / B VJ `� C O tB Cf
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