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� pxx CITY OF PRTOR LAKE Date Rec'd
° � ��` � HEATING/AIl2 CONDITIONING/FIREPLACE PERMIT
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' �j�'NESO'�A 1. Pink File
� z. c��� ca PERMIT NO. �L� ��,,� �
� 3. Yellow ApplicaM
! (Please e or rint and si n at bottom
' ADDRESS ZONING (utn�e ��}
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LEGAL DESCRIPTION (o�ce use only) `
LOT BLOCK AI�DITION pu}
OWNER. .
(Name) � � (Phone) ��'" f� 33�' ��1
(Address) � '�.,l�y� ,'�. �i' L,,
APPLIC
(Name) � (Phone) �� '� V' �7 7 J� ,
(Address) � �,.�( ��
cAaa�ss� �c►cy> {z� coa��
(Contact Person) �L(_ (Phone) �' / � tr 3'"Y7�g �
APPLICANT SIGNATURE DATE b l
APPLICANT PLEASE COMPLETE BELOW
QNEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS .
FURNACE MAKE AND MODEL ' FUEL
FLUE SIZE RETURN OPENINGS � INPUT QUTPU'�
TYPE OF SYSTEM HEATING OR POIWER PLANT
❑Warm Air Plants i PLEASE NOTE: Air Conditioner �
��� Units and Fireplaces Cannot Encroach
❑Crravity ❑ Hot Water '
❑ Mechanical ❑ Radiation � �fo Required Side Yard Setbacks.
Air Conditionin ' Fireplaces with Boa Additions or
❑ 8 ❑ Special Devices
�vent. System ❑ Other Devrces I Cantilevers to the Outside of Buildiags
', Require a Building Permit.
FIREPLACE MAKE AND MODEL '
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J FEE S�HEDUU�E
Industriai, Commercial & Multi-Fam'rly 1% of job cost ' Residential, Gas Fireplace $49.50
$49.SQ minimum ',
Residential, Heating & A/C (New Construction) $149.50 ' Residential, Additions & Alterations $49.50
Residential, Heating Only lNew Con�truction) $64.50 Residential, AC Orsly $49.50
Estimated Cost $ Building Permit #
The Minnesota St�tutes § 32GQ.148
HEATING PERMIT FEE $ " SURCI - iARGF.; " h�s been chun�ed I'or one
yeur effcctive
STATE SURCHARGE $ .50 Ju��� � 21l li) ut�tit .7:�qe 3i1 iu� �.
TOTAL PERMIT FEE $ �j�{_�'O Tl�c minimum surcharge I'or a fec" permit
(OPfice TJse Only) fs ti,,,;, be�inning.luly 1.201U
This Application Becomes Your Building Permit When Approved Paid ��/� Receipt No. � )/A �
7 � •TlJ
�ate b �� y ]By i
BnildinE OfPcial Date
24 hour notice for al! inspections (95z) 447-9850, fa:e (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372