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1'RIO CITY OF PRIOR LA
Date Recd
`� /1, HEATING/AIR CONDITIONING/FIREPLACE PERMIT
I ' N
41 jN\Eso . 1: Gre pink en piCity
le PERMIT NO. // 7 q
3. Yell Applicant
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
1 LI I q9 1000 / al ig
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �, y / `
(Name) 14 V. Z 6 v 0 0 (41 i1. (Phone) %9— l(s' - L J `'''''
(Address) 1 _ 1 1 - 1 q 141013eid Vhil ai' dg° .
APPLICANT Mir Cn �'c- ` (Name) ► ?_ 1 '6 (Phone) v Q dC / (Address) i Cia 1 A _ Ai/ — 5 r 67
(Address) ( ity) (Zip Code)
(Contact Person) ` 6 �, i (Phone) - h/
APPLICANT SIGNATURE /0 011111111 ' .,�.11�// ) DATE /
APPLICANT PLEASE,GOMPLETE BELOW
❑NEW CONSTRUCTION EPLACE ❑ ALTERATIONS
FURNACE MAKE AND ( MODEL ' /� A)g 'TG/ /i elgo / a FUEL 4 4 f
FLUE SIZE )1,0, 3 112 ti RETURN OPENINGS SccA t INPUT V)/ OUTPUT ?a/ CO
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
❑Warni` Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
[ Mechanical fu NA) kce ['Radiation
[t]'Air Conditioning . , L ❑ Special Devices Fireplaces with Box Additions or
YZI� �f ��y Cantilevers to the Outside of Buildings
['Vent. System / ❑ Other Devices
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi Family I% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Resideutial, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Retie atPr! Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended
until June 30, 2013, HEATING PERMIT FEE $ �i , D�
The minimum surcharge for a STATE SURCHARGE $ 39—
"fixed fee" permit is $5,00 TOTAL PERMIT FEE $ 94 4 5()
This Application Becomes Your Building Permit When Approved Paid S b � Recei No. 4/ . 7 ,/
Date
Buntline Official Date ? B
• c ( / •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372