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�-r 7� � �-Y�c�' • � <br /> City of Mound 472-0600 <br /> 5341 Maywood Road, Mound, MN 55364 <br /> �� ��_ <br /> FIREPLACE PERMIT APPLICATION <br /> T� OF FIREPLACE: <br /> factory built installed free standing wood stove <br /> masonry other: <br /> JOB ADDRESS: ( yl� �(�e,t� <br /> OWNER'S NAME �jor-.� n� i..���)�r PHONE: �7/- "7�3 7 <br /> CONTRACTOR: �Q\(�..w�? S}�jveS <br /> ADDRE S S I�� ��3��:�j f-�►•. �,t�.� 5 ; yyUp�s <br /> PHONE: "y7f'�-(��c%�(�:, <br /> VALUATION (include cost of unit & labor) : $ '3 <br /> IFIREPLACE PERMIT FEES 1�1i'tr, StaScD :aiv �iar, viwu:� i.i �E� :Z^-.�.�°�:�C� :�3T^ TucmpT�r,.n,mTppt_ <br /> i <br /> FIREPLACE SPECIFICATIONS: <br /> Type: �X -���Q�� wtsz 2�- <br /> Make:�� Model #:__ 3(p <br /> UL or I.C.B.O. approved? x yes no <br /> Location/Room: ;�-�,r �(�L� � �v.,reX �;;;,,� Floor: � <br /> �c� ., <br /> Explain r10W vented: C��� �GY�o C_�„�,,,n.n�, ,��� Cxi � coa�� <br /> Air space clearance: <br /> CHIMNEY SPECIFICATIONS: <br /> Make: �'ytc;r� Model #: <br /> UL or I.C.B.O. approved? �C yes no <br /> Size (inches inside diam. ) : g" Total Height: i�i ' <br /> Location/Room: ,ry.r.,� -�lw� (,�.,.E, �r�,,,,- Floor: y�c,�, <br /> Used to vent: <br /> Air space clearance: <br /> List special devices on chimney: <br /> Comments: <br /> ���� C� �� c��— �ofr�l�, <br /> Applicant's Name (please print) DATE <br /> APPROVED BY- <br /> Building Official DATE <br />