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HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�I�'NES�'SQ` �. Pink Fl�e PERMIT NO. � _���'/�
2. Green City
3. Yellow Applicant
Please e or rint and si n at bottom
ADDRESS �--, � + ZONING (ot�t use)
3�3 �— � z� t��J o O� �'°� u �` \
LEGAL DESCItIPTION (office use only)
LOT BLOCK ADDITION PID
�aWNER \ U� � � �a 0.�j � Q \ � (Phone) � � °� ' O V � i a a�
1.�
(Address) "� .� �p � . \ �, `.t in b a ) �'�' �''
APPLICANT �' �� �} �j
(Name) '�'0 1 ^ (Phone) 1 � �' � �� ' O � ��
(Address) )� `� �J t � �. � f > ti✓` �-Ft,1 ��
(Addr ) (City) • (Zip Code)
(Contact Person) �\ � � �1 (Phone) � —1 ' ", �� 1�
APPLICANT SIGNATURE DATE � �
APPLICANT PLEASE COMPLETE W
❑NEW CONSTRUCTION PLACEMENT ALTERATIONS
FURNACE MAKE AND MODEL ''C� 1^ • S`� �� S — UEL �, e�.
FLUE SIZE RETURN OPENINGS INPUT 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 Setbacl�.c.
❑ Mechanical ❑ Radiation
❑Air Conditioning ❑ 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
FEESCHEDULE
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 Cost $ Building Permit #
"SURCHARGE" has been extended � � S �
until june 30, 2013, HEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ �$0
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid � [' i /� Receipt No. �
.J '7�
Date � /� By , '
Buildin¢ Ofticial Date �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372