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( c . PRi CITY OF PRIOR LAKE Date Rec'd
i c HEATING /AIR CONDITIONING /FIREPLACE PERMIT
H
INNE; 1. Pink File PERMIT NO.
2. 3. Yellow Applicant /�'°
(Please type or print and sign at bottom)
—
ADDRESS PV/24,N,Voo ZONING (office use)
40 , -t, s , E,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
•--• )1/ki ((Na G WNER /t-C� 1 r (Phone) ‘0'? — 4 Y
(Address)
APPLICAN
(Name) I V _ If V . r . (Phone ‘tal- O ���C 7
(Address) 4 3f If 1(4 ( ' L)) Kg /'23. 55
(Address) (City) / p (Zip Code)
( Contact Person) akia ( �� 6
�
J (Phone) 'oi' Wg ' l�d6 7
APPLICANT SIGNATU' `.!;' DATE / /-g
APPLICANT PLE - SE COMPLETE BELOW
ig.a ❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
/1 /vr �Jn / CL FUEL
FAQ MAKE AND MODEL /it
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants El Steam PLEASE NOTE: Air Conditioner
❑Gra ❑ Hot Water Units and Fireplaces Cannot Encroach
echanical ❑ Radiation into Required Side Yard Setbacks.
Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
Cantilevers to the Outside of Buildings
EVent. System ❑ Other Devices
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 �0'
Residential, Heating Only (New Construction) $64.50 Residential, AC Only kerk4C $49,50 S �
ad
'- `' - -`-' Cost $ Rio,--- Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date
Buildin¢ Official Date . //S Bye . - 4.,.
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372