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4 vRto CITY OF PRIOR LAKE Date Rec'd
� ' 4' HEATING/AIR CONDITIONING/FIREPLACE PERMIT
it1-7 AC
4'INNEsdo I.Pink Fae PERMIT NO. l L_ Ql
_ 2.Green City
i,Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
17223 tJoociU'ievi C.
LEGAL DESCRIPTION(office use only) .
LOT BLOCK ADDITION PID
OWNER '
(Name) c� t I f y• 1�0'C-13 K/65O h (Phone) 15 2- 2Z6 - 215 0
(Address) ( 7223 VJ0Oc U i e vv Gt, .
APPLICAANT
(Name) D010-6-Kfril D010-6-Klk1ri.14A1Y et-v114-1 i4J (Phone) g52--i14-3 5S2.-
(Address) 040 Vd• R 2`"i SF, 61 A-G-vvi..ivt �-rt 55420
(Address) qq (City) J (Zip Code)
(Contact Person) S e.oif ki t'"). O-&4'C (Phone) 61 5 2 - 4 -3 S S 2-
APPLICANT SIGNATURE .,►4. DATE 6- 1 7-12_
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION (REPLACEMENT 0 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
0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
❑]Mechanical 0 Radiation into Required Side Yard Setbacks.
Arr Conditioning 0 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 $49.50
Residential,Heating Only(New Construction) $64.50 Residential,AC Only $49.50
Estimated Cost$ lid-00. Building Permit #
The Minnesota Statutes*3268.14$
HEATING PERMIT FEE $ 4q, 'SURCHARGE"has been changed for one
year effective
STATE SURCHARGE $ 5,0O.% July 1,2010,until June 30,2011.
TOTAL PERMIT FEE $ 5.4,50 The minimum surcharge for a"fixed fee"permit
(Office Use Only) is;$5.,b"��inning July 1.2010
This Application Becomes Your Building Permit When Approved Paid �-/ Receipt No.,di r— 3
Date By
Building Official Date 7102-Illi ,1, .
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372