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11-27—'17 12:45 FR4M— T-194 P0003/0005 F-586 <br /> ���Z'�?.;���CA 'C�%A,'�YQN S <br /> ,,; :�,:. <br /> .�. �. (. )' . <br /> 'BA ED.tS���-;2 2`�TAT <br /> S Q.0 S. �:STA�;:;;..:. <br /> ❑ Yes,this scction applies <br /> Thc replacement of a Residential fixture or appliance that meots all tiirco of thc folio�ving requirema�ts: <br /> 1. boes not r�quire modification to clectrical or gas service. <br /> 2. Has a total cost of$500.00 or tess;excludins thz eost of'tha ftxture or appliance:and <br /> 3. Is improved,installed or replaced by the homaowner or 1ic.�nsed contractor. <br /> Skip ncxt section,if this applies; Cost of Permit $ 15.00 <br /> Statc Surchargc $ 5.00 <br /> Mail-In�'ee(If Applicable) $ Z.00 <br /> Totsl Permft Ree $ <br /> .. ,. .... . . <br /> ;.;... ...:;.;•��E�1�Y�;�EE:CAY;CUI�,�4TYON S -`:rOBS OVER$500.00:;':;,.'.;;.; <br /> Yf above does not apply;follow guidelines below: <br /> 1. CONTRA(."r PRIC� �`is 1.25%of contract price with a(Minimum Y�ee of$50.00) <br /> �� �� �� !, $a, *�, � . : <br /> ��� ��� �'7 � b .11.. A.. <br /> 2. STATE SURCHARGE n { � Q Q�,p <br /> L�� � xE.��� � . <br /> cn "'i" e <br /> 3. POSTAGE 8t HAND�,ING(Only on Mail-Tn Applications) � � ��:x� <br /> 4. TOTAL PERNIIT FEE Add Lines 1-3 Above , �' {b� <br /> � ) ������'��af <br /> ■ � CONTRACT pkTC� or J'O� COST means the actual or estimated dollar amount charged for the <br /> pamitted work including materials,labor,profit,and other fixed costs. Tt is the amount to be charged <br /> to the custorner for the work done. If any matzrial,equipment,labor or installations are furnishad by <br /> the ownor�tenant or any other parry,the reasonable market vsallue of such items must be added to the <br /> estimated cosE or contract price for parmit fee purposzs. 1'n thz avent tliat there is a dispute on the <br /> amount of the job cost,the City may request the submission of a signed copy of the actual contract_ <br /> .. • , ... . . .... <br /> , ,;M�HAI�IIGAL�'PERMXT.A;P��;YGATIONAGREEMENT;. ::;:;::: ,:`..:;:' . .:�. <br /> The undersigned hereb�applies to the Ciry fbr issuance of a Mechanical permit,agreos to do all <br /> work in strict accordance with the ordinances of the City and the regulations of the State of <br /> Minnesota, and certifies thflt all statements made on this applieation are complete, true and <br /> corc•ect. <br /> Applicant's Sigr►ature: _ _ . ,�# '�' G,l���� ,L. <br /> 3 <br />