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�� rRl � CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
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�IIN ' l. Pink File � { _� �7�
2. Green CiTy PERMIT NO / �
3. Yellow Applicant �
lease or 'nt and si at bottom
ADD�$$ � A ZONING (ot�ce use)
1y93 1������� - Ni�e
LEGAL DESCRIPTION (oi�'ice use only)
LOT BLOCK ADDITION PID
OWNER k (�
(Name) 1 �� : t -P '� «A'� (Phone) �P� a' a3� r-.S�? �
(Address) � � �P '� �Q �� • �lClC
APPLICANT .�•L_ C £II��SI S � � ) q � �`� �
(Name) � Phone � ��p
(Address) �,� � � � �G ���'� �.� � � �'C�" ��` ,/' �� �
(Addr ss) (City) (Zip Code)
(Contact Person) (Phone) �� �a � � �O �� � 3 /
APPLICANT SIGNATURE DATE � �
APP ICANT PLEASE COMPLETE BELOW
�NEW CONSTR TION EPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL �I I� �� v � /"� FUEL
FLUE SIZE P� � �`� RETURN OPENINGS `� INPUT '�,OC� O 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 5ide Yard Setbacks.
❑ 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
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 � Cost $ Building Permit #
"SURCHARGE" has been extended '
until june 3(Y, 2013, HEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .5
"fixed fee" permit is �5.00 TOTAL PERMIT FEE $
This App ' ion Becomes Your Building Permit When Approved Paid C �t �� Receipt No. �/_
��,, _ � i„ ��� lO
'��'� � ��� �r Date � � By ..-�'^
BuIIdine Official Date ���
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota 5treet S.E., Prior Lake, Minnesota 55372