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�, . . <br /> . . <br /> - 3���.�Y� � ����1.T <br /> Wouci stove with flue <br /> _+��M. Wood c�mbiiiation Qr add-on <br /> Factory �replace with flue <br /> Factoty Firtplace {s) �___ Freestanding Masonry <br /> Wooct Stc�ve (s) Franktin, other <br /> Hranci Name Mode! Na <br /> Mfgr's MIn., Clc:xranc�s, sidc , reu , min. t7ue dia. r <br /> Y�L__T�S?N <br /> Nu. Kitchea �xhaust ductod recirculating cfm <br /> No. � Hath I;xhaust (must be ductcd outside) cfm <br /> N��. �� Qther F�ns: Locations � cfm <br /> ��,�'T�1tAGE (MUS1' BF AP VED BY FIRE MARSHAI.) <br /> lnstellation Removd <br /> Fuel Qil: gallo underground inside outside <br /> _,��. LP Gas: gaU�ns <br /> .�_�_� �ther _^_.�-- _____.. Gas opening <br /> P���1� ��%F�CA,�,�L1LA�'iAiy <br /> 1. 1.25% of Cantra�t Pricc* or n �'ge (�33.00) � <br /> [�C� � x .Ol?S $ � � ' � s <br /> (contract pricc)� <br /> 2. �tate Surr.ha�gc; ** Acld the State Building Caie Division ' <br /> SurchNrge to each pennit. _ x .00OS $ �' � <br /> ar $.50, whichever is greater (concraac price) <br /> 3. Po� � and Ha lin (Qniy mail-in applizatians) $ __ ,�.50 <br /> 4: TOTAL �ERMIT FFE (Add lines 1-3 abovr) $ <br /> " �ONTRAC:T PitIC�or 108 COS7'mean�rbe actu�l or eatimatod doUar umouat charged for tbe permitud <br /> wo�k fucluding mattrials, labor, prvftt, $nd othsc fized costs. lt is thc amount to be char�ed to thc <br /> cu�tUmer Pur the work dune. If any mutecial,equipmeat, labor, or installatian gtc furrtiahed by the owarr, <br /> tensnt or nny other patry the reaaanahle market valur of ruch items muyt t�e adcied to the estimated cost <br /> �r carrcract prtce foc pennit fcc purpoaes. In tha evt�t thpt t#ure is c dispute on tbc amount of thc job cost, <br /> the Cicy may requese che submiaaion of a �igaed copy of the acmal couiract. <br /> ** Tbe STATE SLRCHARGC is .Q005 ut'the contracc pria under SI,OW,WO or S.S�) . whichever is <br /> grenter. For v�uutions ovcr S1,000,flOQ call the Dcpartment of Inepectionat Serviccs for the price. <br /> The u»dersi�ned hereby arplies tc� the Ciry for issuanCe of a Mec�►aniral Petmit, agrces ro do <br /> all work in strict accordaru;e with the ordinant:es of the City anci the regulations of the Minaesota <br /> : Statc Building Code, uc�i c�ctifies that all statements made on this application are romplcte, true <br /> atfd COl't�CI. <br /> Appiicant's Signehue: _ \ Date: �� 7 <br /> Appmved By: Date: <br />