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<br /> � �, i.�� �.7�t 1+ a�,,�.'iR +` `'��
<br /> i� . , m i�•r � � t�{ , .
<br /> '.��'�' � i t r�i Far:��ll �I�'A =:�'f%:'C
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<br /> �i�i .'v:�"u,; !l,Y,
<br /> �� � ',� �'�" a:� '���.
<br /> Yes,this s�tion app(i� . '
<br /> Tl��rep(ace�me»t nf a ResidendAi s;,.. �or a������„�,thett t»eets All three of the folioWl
<br /> �. f)�.�'►eyqire tt�od't�"ication to el ��r�Nire�ner�:
<br /> 2. J-1ae a �C09!of$SOO,pQ or ie `�cal or gas se�vice.
<br /> 3. fs improvecl,insrnlled or r �IAce�"�llli�the cost of the fixt�.�re or a
<br /> �) �lry th�homeovEnler nr licerr,v Al�linnce:end
<br /> erl contractor.
<br /> Skip nexc•secticm,lf thie spplies; E'.�st of Perm ff
<br /> Stitte SurchArge �---�5•20
<br /> Mt�il-r»ree{lf AR��ir..��le) �"`-''Sn
<br /> :j:�,,_r---. ,. 'I'e�nl Permit Ree �--=-t-5(?
<br /> �,�.,�Gi;[..•:i.l�'�51 f,,l i�i+`% -----�
<br /> ' ;%',;•.:�,::.t.::_. .i I',r�'
<br /> M � �.LS�
<br /> tf aFx�ve d�eg not a�ly;follow guidelines fje�� �W ,. N,:'
<br /> �al{:;,;�:�• :: ;���.;�� ,
<br /> w:
<br /> 1•. �GONT�►c�r r__�� �� i,y l.25"/n ot'
<br /> contract price with n(M�nm Fee
<br /> af�:3!9.Op)
<br /> 39
<br /> �---�-_� x.Q12S fi
<br /> �
<br /> (r�,n»ncrn�icF�) • �_-_______-----_..
<br /> 2. STATESUR�"A�nr,� �p# ^ {mfniitinm�3S.itf1�
<br /> Add tl�Sl�Ate Hld�{C'ocle niv. �urch$�e�Iklnimun�Fen ofF.50)
<br /> o,G
<br /> .---- ��-�_._ x .00�S �; .• ��
<br /> (coflfMel��ri��:} -' �--- _�
<br /> 3. 1'()SI'AtiE&.HA,NT)L.INf.;(Only on MAiI-fn Ahplications� R �minimum'R ,Soj____.._..
<br /> --_.�______�_tS�(�..._---._..___
<br /> 4. TOTA.i..FERiM1�'�PI.`F.(Ac{d Lines'1-3 Ahovej � �'
<br /> � �
<br /> n 'F C.:C) ------�.1. i
<br /> N7'Rl1C"t' P�t)CF c�r 10(3 f;pST meanq che fsch�si nr --"""•-_-_
<br /> het�tttitted work includin,�mRter;atg, lalx,r ��mA� �O�IA�amount cha�ecl for r1►e
<br /> tn the r.i.�stomer f�r the work done. �f ai�Y�at r�ial'�eqnlipment,�j h�r'instaUetlons Rte fltrn�shecl I�r
<br /> �mt ta !�e chtu•�qed
<br /> the owner, tenent or Ar1y qtl1er�>p�•ly�{��9n198bIC t11fti'IteT,V8IL1�!Of.4UCI1 I�CI1t3 I'11qg��A
<br /> eqtimAted cost ar cont+�ct pr�oe f��. ��1� ,� �����4e� ttt tl�e event th�tt �� t°N�e
<br /> Aq)ou)tt �f the.�pb c�,qt�the C.ilx�na3+ reqqa9t N1C �UbF1113.4i011 Of A 91 � � ,s a dispate o.a d��
<br /> Rn �pY of the actuaf aontract.
<br /> " '�'�The STATP;5iJRCf1ARC1F is.pp05 n}���guildin�;!.)epRrtment At y52 24q,,,}r��for the
<br /> � "i,;i` .,:��.:.;;,y�a;�,j�!,.;i:�,;> ' � � f�'ice.
<br /> �� .. � �; :�.�;
<br /> y...d.;�_..
<br /> . .�:'1 !i� •l I' 'i•t�;�' 'y
<br /> ��i it:yf::'i���'��'�:�,`i�.�l���.
<br /> w:fi I
<br /> T'he �mde�•siqtt�d Itereby applies t� the�City for i�.suance oi'a:Mechenical Permft, Q r�es r.o
<br /> 1+t�ork. i�t StTiet aeeordanee with tl�e cirdinane.es of'the ('i�.y ancl tlr� reRulatio118 & the ��� ��
<br /> Mtnnrsara, and serti�fi�.s tli�t all siAtelTIB11f9 �nad� on tlais anPlicati�n are complete, true AT,ICI.
<br /> e�l'zeCl:.
<br /> �np�icant's Si�nature �
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