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06/03/2016 15:38 7635354379 GOLDEN VALLEY HTG PAGE 03/04 <br /> '+ , <br /> � ' � . .,�� ,,.,,1,... <br /> ! y. ,;(r;�;.?�,.�;,t�:: ,< <br /> I w� �`:4!1��1/�!�r-"� <br /> r;:�,; .{�a�. <br /> � ❑ Yes,rhis section agplies <br /> I Thc replacement of a esi ' 1 fixture li oc thac z�ueets all chree of t�►c foitowing requ.iiremcnts: <br /> i <br /> , �• P�-�reQuire nuodiftcalian tn elecirical or gas scrv�ice. <br /> ' 2_ �ias a to eost of$SOO.OU o�r less;e c ' the cost vf the fuctuze or applfance:a�ud <br /> 3: Ts ux��+oved,installed or replaced by thc hono,eo�,e,r or�acensed eqz�tractor. <br /> � S3cip n�,xt geCtion�1£t�lis app��e8; Coat ofPermit S �5,00 <br /> StdfC$IICC�1aI$e $-�,.� <br /> , Mail�ln Fee(If Ap�licable) $ 2.00 <br /> Totat Penoouit Fee $ <br /> .:J� ���:"s 'x:�:- <br /> — ��'k:}, <br /> If above does not apply;follow gu�idelines belvw: <br /> � <br /> 1. CO CT P *is ,�_25%of coulxact,price with s(�1Tinimnm�'ee of$SO.OU) <br /> 0 0 X.0�25$ O�UC� . Dl� <br /> ^_ ��� A�) (miaimnm$SO-00) <br /> 2_ STATE SU�C�ARGE ^� <br /> _ x.0005 $ ��C/ <br /> (contacc price) — <br /> 3_ �OSTAG�&HAN�I,ING(Only on Mail-in.eipplicanions) $ .�� <br /> 4. �'OTAL pER1VIIT�EE(Add I,i�oies 1-3 Above) � �v <br /> ■ * COIVTRA�,Ct`PTtiC$ vr JOB CQST meant, tb�e actual ox estimated dollar amou,ot charged for the <br /> pezrnitted wor�c incIudiicxg materisis,labor,pro�i�an,d other fxxod oosts. Tt zs the ampuz�t to ba charged <br /> to tbe cusDomer�or t11e�vocic dono. If auy Au,aterial,equx�men�lsbox or installat�ons are �'itz�o,ished by <br /> ' the ow7ue�,t,Cnsnt oz�Ai1y ot}�ez pA1t}•,t$e xes,qpnable market value o�f sach ite�ms miust be added to the <br /> escimated eost or contraet p�nice for pe�it fce p�poses. In the e^�rcnt that there is s dis�ute on #he <br /> amouut of tiie job cost,tbe City�oo�ay request t�e subxnission of a sig�aed copy of the actuaI contract <br /> -f, •r <br /> r.� <br /> ,i:�y ��:i!.•���i��t' <br /> The undersi.g��od hereb�r app�ies zo the City€oz'issvance of a Mecb�aAical Fermit, agrees to do ali <br /> worl� in stiriet accozdance with the ordinanees of the City and the regulatioz�s of rhe Srate of <br /> Miuutesata, and e�rtifies that a11 statements made on this appl�cat3ion aze cvmpleke, true and <br /> correct. <br /> ' 1 /� <br /> Applzca.nt's Si�gaature: ' � � T)ate: U/ <br /> 3 <br />