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• �'QQP �����i_,��J 1��T <br /> Woai stove with flue <br /> � _.___..__. woc�d �Umbii�ation or add-on <br /> _� Factory freplace with f7ue <br /> �__ Factory Fircplace {s) �__ Frecstanding � Masonry <br /> Wc�oci St�ve (s) Franklin, other <br /> Hranci Name Model No..�________, <br /> Mfgr's Min.,yCleaiances, side"� re�u , rnin. t7ue dia. <br /> �j�! ATION <br /> No. Kitchea L"•xhaust ducted recirculating _ cfm <br /> No. +�_ Batti Lxhaust {must be du�ted outside) �f�i <br /> Nc�. _�� Chher F�ns: Locatians � ` cfm <br /> �`IJ�L• �'�',S��AGE (MUS1' BF APPROVF?D BY FIRE MARS��AI�) <br /> Installation Removal <br /> _ _ Fuel nil: __` �a3lons _� und�rground _ inside outsidc <br /> ..__�. LP Gas: � Kallunti <br /> .Y.----� Other _�__...___ _____ Gas agening <br /> ` , � <br /> ��/�f--����.__[tv;`l, ?L,f f/'1��-E=� � �r<�.''���-,c�- <br /> PE����' �'���B1tC A <br /> l . 1.251 of '�jt�a�t Price"' or �'ee (�35.00) <br /> ��_.. x .0125 $ ;� � v� S� <br /> (contract price�� <br /> 2. 't t� Surc:ha�gcj ** Add che State Buildi g Caje Division <br /> Surchargc to each percnit. ��_����= _ x .00i)S $ � �� <br /> ar $.50, whichever is greater (concract pricc) <br /> 3. Po� a�t� and �1a� l� (O�IIy mail-in appticativns} $ � <br /> 4. 'I'UTAL PERMIT FFE (Add liries 1-�3 above) $ �j �/ � �� <br /> " C0IVTRACT PI{!C'�or 1OB COS7'mearua tbe actual or tatimated doilar nmc�unt charged for the permitted <br /> work i��cluding materials, labor, }�roftt, and othsr fizcd costs. it is thc amount to be thsu�ed to thc <br /> cw;romcr Pur the work eiune. [f any mnterial, �quipmcnt, labor, or installatic�n utC fue-r�iahed by the owner, <br /> tenanl ot tiny�thtr Qutty the rcasnnahle niarket vxlue of such items must 6e added to the estimatad cost <br /> �r coiitr�ct price for ptrenit irc purposes. ln th4 event chut there is a dis�+utc on thc amount of th�job cost, <br /> ihe Ctty may requ�st the submissiva of a si�nM topy of the actoal couiracc. <br /> *'' ?he STA?E SL'RCHARGE is .(�US uf the eontract price undcr �1,000,0()0 or 5.5c) - whichcvrr is <br /> greator. Fsit v�luations ovrr fi1,00p,Q00 �all the Departrnent of Ineptctiva�l Services for tht price. <br /> The undersigned hercby applies to the City for issuanCe of a Mechani�ai Pennit, agrces to c�u <br /> all work iti Stri�:t accordaru;e with the ordinant:cs of the City anci the regulations of the Minnesota <br /> Statc IIui)di�g Code, �uui certifies that all st�tements made on this application are rvmplete, tnie <br /> and correct, <br /> Applicant's Signature: _ ��'� �-� , w,� Date: �L� -`� � � <br /> Approvec! BY: Datt: <br />