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� 4 p RIp�� CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT � Z,/ Z- _ I Z
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�INNESD�P t. Pink File
Z. �n �; PERMIT NO. � _ ��
3. Yellow Applicant
' t and si at bottom
ADDRESS ZONING (ot�'ice use)
/ 71 L15 �ea sa vtt �eaa�oc..v L�n� 5W
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
R '
ame) �.-.OP'1��1t�► t� , (Phone) ��5a 55 CI 3
(Address)
APPLICANT
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE m• �CX� DATE I — ! oZ — l
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
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 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.
PLA AND MODEL �S ��� �� �!�/� [s
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 ;ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013,
The minimum surcharge for a KEATING PERMIT FEE $ � �
"fixed fee" permit is $�.Ot� �TATE SURCHARGE $ .50
rOTAL PERMIT FEE $
(Oftice Use Only)
This Application Becomes Your Building Permit When Approved Paid� S �� Re pt No. �.' ?? �
Date Z . �Z, ��L
Buildin¢ Ofticial Date
24 hour norice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372