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y � • �10-10—'16 13:58 FROM— T-212 P0003/0004 F-256 <br /> i�-=� -�-�`._ '-- _—• - . - ' � .. _�('• _ - ,.— - _ ,- - �: <br /> �� ._ _ �- = .. _�:__ - - �. 's� - � �:� � -— _ <br /> �y''�;j _l. f.,r� ( �{ S <br /> �CCs�1�CC�L��iJ���AG��__��'y^' iw ��� - _ .Q:� � �� --�^� T •'�.-.�• � <br /> �R Ie'ia" <br /> Q 'Yes,this section applies <br /> Thc replacement of a Residential fi re pr� liance that meets all thres of ChG following requirements: <br /> 1. Does not requirc modification to electrical or gas scr�vice. <br /> 2. �ias a total cost of$500.00 or less; x ludin the cost of the fixture or appliance:and <br /> 3. Is imprpvcd,installed or replaced by the homcowner or licensed contractor. <br /> Skip next section,if this appIias; Cost of Aermit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-[n Fee(IfApplicable) � 2.Q0 <br /> Totsl Pern�it Fee $ <br /> �� � � '� ��. � -- - <br /> If above does not apply;follovv guidelines bclow: <br /> 1. CONTT2ACT PRICE *is 1,25%of contract price with a(Minimutn Fee ofS50.00) <br /> � ZZ� � -�'S� <br /> .� x.o�zs� ,� <br /> (conaact price) (minimum 550.00) <br /> 2. STATESURCHARG� � <br /> '3 '-�- <br /> x.0005 $. � <br /> ConlCaCt priCe) <br /> 3. POSTAGE 8c HANDC.ING(Only on Mail-in AppIications) $ 2.Q0 <br /> 4. TOTAL p�YtMYT F�E(Add Lines 1-3 Above) $ �/ � <br /> ■ * CONTYtACT PkTC� or JOA COST means the actual or estimated dollar amount charged for the <br /> permitted work including materials, la6pr,pro�#,and other fixed costs_ It is thC amount to be charged <br /> to the customer for the work donz. Tf any rnaterial, equipment, labor or installations are furnished b� <br /> the owner,tenant or any other parry, tl:e reasonable market value of such items must be added to the <br /> estimated cost or contract price for permit fee purposes, Tn the event that there is a dispute on the <br /> amount of the job eost, thc Ciry may roquest the submission of a signed eop�of Che aet�,ial contract. <br /> ���,Y:�_�. j. •� - -_,�. r� - �� -� "' - <br /> _ . :: . : _= - . <br /> _.=� . . � . . . = . . .- <br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees 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 that all statements made on this application are complete, true and <br /> conect. <br /> AppliCant's Sign�ture: . ��� � Date: � /Q � <br /> 3 <br />