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i-11 6875
o pRip CITY OF PRIOR LAKE Date Rec'd
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HEATING /AIR CONDITIONING /FIREPLACE PERMIT
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2 Green City PERMIT NO . � %3 j�
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3. Yellow Applican
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(Please type or print and sign at bottom)
boLeo {_d s� SC ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ° I _ 5�' - 8I b
(Name) (Phone) [PS
(Address) 0 �C 0 Op . S S
(Name)
&.fy.z..._ (Phone) 9SZ- V
\ Phonne) ` 9 I *�
(Address) 2.2n() 0 k .L)\ \3� E)Ltin JY ((1f 553'.51
(Address) (City) (Zip Code)
(Contact Person) (Phone) l
APPLICANT SIGNATURE 11116M1111111116 DATE 2 111 1
• APPLICANT PL 6 • S . COMPLETE BELOW
el.- _ (.. � - ❑NEW CONSTRUCTION ' EPLACEMENNT El ALTERATIONS
FURNACE MAKE AND MODEL rf) lac, �nac _ QS FUEL a S
0 �
FLUE SIZE RETURN OPENINGS INPUT 000 OUTP T
TYPE OF SYSTEM HEATING OR POWER PLANT
['Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
DGjavit ['Hot Water into Required Side Yard Setbacks.
W. echanical ❑ Radiation
g. • it Conditioning 111 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 ',49.51
Residential, Heating Only (New Construction) $64.50 Residential, AC Only
The Minnesota Statutes § 326B.148 Cost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $ LIZ SO
The minimum surcharge for a STATE SURCHARGE $ S. 0 U .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ ' jL /. S 0
This Application Becomes Your Building Permit When Approved Paid i Receipt No. Date � f r <I �I . 7
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Buildine Official Date / � By �
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372