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(�y������ �E�:30am From-CiTT uF u�ta�, ror�w+���v�r • -'- <br /> ���-�-�wrrrn-,�7']IOrits) <br /> ZQD2 St�.�jp,tute []Ys�TL►►i�Setdon Apptics <br /> The replacc�ant of a Res��fixtura ar amolia�nce that raee[s all throe o�the fotlowing re�uirunents: <br /> �) �requize raoditicatia�to etect�rical or gas servi�ae. <br /> 2) Has a�j of�SO(3.00 or kss; 1��8' the aost of che tixture or appiianca: <br /> and <br /> 3} Is improvad,iststalled or replaced by the bameov�rtter or licensod contractar. <br /> Skip next sec�ion: Cost of Pa�nit $ 1�.QO ......� <br /> State Surchargc$ .50 <br /> Mail-Yn Fce $ ,,,1 S� <br /> If above daas not apply, foltaw guidclines be6ow: <br /> 1. Cn �t rice*is.012S9�o of job with a��e�m Y�'ce oi tS3S.8Q) <br /> �� � o._- <br /> 0 6a`� x.akzs $ � 4 <br /> (contraci prico) (rr.i�imom 535.�0� <br /> 2.Stats 9urcbar�e.'�*Add the Stata HUilding G�cle Divisiam a�in{ ��g of{$.50) <br /> `�S(6b0 ``� X ,QOOS $ �a� � <br /> tcomract price) (rr,ia�mum S.so) <br /> 3.,g e� �gndlia�(OAIy»�a�+Lr wpplicMM� $ 1•SQ _.._ <br /> � �'O <br /> 4.T4TAL FERMIT FEE(Add lines i-3 above} $ ..53• <br /> +CQN'CRACT PRICfi cx JOB�091':c�ans tAt�or c�stimatui doUsr amoum cha�ad for�Ite pe�meued work includine <br /> mmusia:b,labw,pro9t,a�nd otha fixed mx�s.h is chc ama�n.t m ba ch�ynci w the�er for the wak done.if aay tnatarlat, <br /> equipmen�l�bot,or ia�tellatian ia furnist�od hy ct�owner,ior��s a any eqKr party eht rea,wnabks Rmrlac v�t�a of such it�ra.s <br /> must bo addea to tA�enimRoed cost or carrt�ct price tar pamic ke purya�e3.:R NiC C��rnt that tharc is a cliasn.te on the amouat oF <br /> �h��ob oost.rita Cisy mar rsqua�c me wbmissio�a ota�igned uRapy 4t'the NCW�i conaa�. <br /> *"The STATS SURCHAR4t:.is•.a005 ofiha contracl p►icc un�er E1,000,000 or a,56-whichever's�rdtter.Fur valuMions ova <br /> $I,OOO.00b esil��c Dtpa�ee�x uf lnspa�Ron�1 Savices for tt�c peicc. <br /> Thc undasi�ncd henbr qpplits�o tha City bor issuaner of a M�icai Permic,a�rees ro da a!4 wotic in suicx accQrdxncc with <br /> the ad'm�ncss of the City and tt�repuletiatw of tht Miinesota Statn Seniding�a4e,an4 aertitics zhut aIl s�tcmma madc on this <br /> applicsl;iot��1rc comptete,t�ve�ad oon�ccx. <br /> Appiicant'a$ignatua't �------ Dat9: / /� 4 <br /> A,pproved Hy: Uste: <br /> � � <br />