Laserfiche WebLink
H V A C & Gas Piping Permit Application <br /> q 600 Rice Street East • Wayzata, MN 55391 PERMIT#: <br /> � � 952.404-5301 • 952.404-5318 (fax) RECEIPT#: <br /> www.wayzata.org <br /> SITE ADDRESS PROJECT VALUATION DATE <br /> 7 <br /> ��, ; � N ����-���� �_��� k������� izo�� � o�.�zz iz� � �� <br /> OWNE�'S NAME PHONE NUMBER FAX NUMBER <br /> l<;� i1���✓�� ��,��;������� `1 �Z-��( - �,�l`� <br /> OWNERS ADDRESS CITY STATE ZIP <br /> � ?�`� /1� ,*�'�n���� �U�n�a l�l,���, ���t'�' /l/',�1/ ��� >`t I <br /> APPLICANTS NAME PHONE NUMBER FAX NUMBER <br /> i���(,� S r��������1� �t�Z � �� 5`� 7 Z 17 <br /> COMPANY NAME E-MAII ADDRESS STATE LICENSE# <br /> �'ruv�lv N-�,%�fi� ��al �i� (�:�Irh���,��� Q✓tf��p;�� �� vOl�t��►flol�l <br /> COMPANY ADDRESS � CfTY STA ZIP <br /> �5�� i���sh� +�� f��-e S �c�e� ������r,e /�1,/� SS 3`�5� <br /> DESCRIPTION OF WORK - r <br /> +— —-----�-�-G�� '��V+�'f_�?�,�" 1��(�L� - --- ---- --- <br /> CHECK ALL BOXES THAT APPLY: INDICATE NUMBER OF EACH: <br /> ❑ New Building or � Existing Building: AVAC Equipment GAs Openings <br /> Number Size Main <br /> Furnace � YDK �k Furnace <br /> [�Single Family Residential � Principal Building <br /> � Single Family Attached � Garage B011er BolleY <br /> � Two Family Residential �Addition Gas Fireplace Water Heater <br /> � Multi-Family Residential � Remodel Heet ExChanger Range <br /> � Commercial � Repair Air Conditioner Firepiace <br /> � Public ❑Swimming Pool <br /> ❑ Mixed Use ❑ Other: Ventilation Dryer <br /> Other Other <br /> ,COMPANY NAME 'CONTACT PERSON <br /> ADDRESS CIN STATE ZIP <br /> PHONE FAX/E-MAIL <br /> e <br /> This permit becomes null and void if the woric authorized is not commenced within 180 days of the date of issuance,or if the work is abandoned or <br /> suspended for a period of 180 days.All provisions of laws and Ordinances goveming this type of work will be complied with whether specified herein <br /> or not.The granting of a permit does not presume to give authority to violate or cancel the provisions of any other Federal,State or Local law <br /> regulating construction or the pertormance of construction activities.This permit may be revoked at any time for due cause. <br /> • � . � � • � . . � � � � � � - � � <br /> APPLICANT'S SIGNATURE DATE . <br /> �/ � �`�� , � �'� i l� ��u/� <br /> � � <br /> USE: AUTHORIZATION TO ISSUE: DATE OF ISSUE: � � <br /> PERMIT FEE: L�� '� <br /> Fees: SURCHARGE: �✓ ��y <br /> Greater than$50,000=$1,000 plus 1.5%of amt.over 50k+surcharge OTHER: <br /> $0.00 to$50,000=2%of valuation; minimum =$30.00+surcharge <br /> Surcharge= .0005 of valuation, minimum 50 cents TOTAL FEE: Z�� 1 � <br />