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o � PRip� CITY OF PRIOR LAKE Date Rec'd
� � HEATING/AIR CONDITIONING/FIREPLACE PERMIT
� � 2���7-c/Q�-�E
�INNESO'��' �. P "� F11 pERMIT NO. Q�
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3. Yellow Applicant
lease or 'nt and si at bottom
ADDRESS ZONING (ot&ce use)
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LEGAL DESCRiPTION (office use only)
LOT BLOCK ADDITION PID
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APPLICANT
(Name) ' (Phone)
(Address)
� P�� s� (City) (Zip Code)
(Contact Person) ����� hone)
APPLICANT SIGNATURE DATE /4� �
PPLICANT PLEA COMPLETE BELOW
❑NEW CONSTRUCTION PLACEMENT ❑ ALTERATIONS �
FURNACE MAKE AND MODEL ��. ��-�c�— S S (i�� � FUEL �
FLUE SIZE RETURN OPENINGS INPUT �j�f3d�{� 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 Fireplaces with Bog 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
"SURCHARGE" has been extended �ost $ Building Permit #
until �une 30, 2013,
The minimum surcharge for a HEATING PERMIT FEE $ �� ��
"fixed fee" permit is $5.00 STATE SURCHARGE $ �
TOTAL PERMIT FEE $ ��� _S� •
(Oftice Use Only)
This Application Becomes Your Building Permit When Approved Paid p �+ Receipt No.� �� �
�7 T
Bulldin� Official Date Date / �/�� By �
24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372