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From:GOUNTRYSIDE HEATING & COOLING 763 479 2518 05/21/2013 14:03 #742 P.003/004 <br /> 4}. ...._ ,; ...�,. .. .., _ - <br /> �=��^���,;�x �: : �; <br /> _. .. t .. ._ . . <br /> „ � <br /> ,. • <br /> ,. 2 � 5: �, x� . . . . <br /> .. . y '. ' ' .�,, <br /> �s;�t�^��". . .. � <br /> ❑ Yes,this section applies <br /> The replacement of a Residenrial fixture or annliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5•00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Totai Permit Fee $ <br /> =���_ �t���' :��r,.,. �. . . .. .,.. '� _ " �.. <br /> �. , ..,. <br /> 3�'Y1..�i-,��..�.�•�.�' . ., � w� '�. <br /> If above does not apply;follow guidelines below: <br /> 1. CONTRACT PRICE *is 1.25%of contract price with a(Minimum Fee of$50.00) <br /> �5�� �� x.0125$ <br /> (contract price) (minimum 550.00) <br /> 2, STATESURCHARGE <br /> x .0005 $_____ <br /> (ccmtract price) <br /> 3. POSTAGE&HANDLING(Only on Mai]-In Applications} $ 2.00 <br /> 4. TOTAL PEItMIT FEE(Add Lines 1-3 Abovc) $ c��• 7� <br /> ■ * CONTRACT PRICE or JOB COST means thc actual or estimated dollar amount charged for the <br /> permitted work inclvding materials,labor,proft,and other fixed costs. It is the amount to be charged <br /> to the customer for the work done. If any material,equipment,labor or installations are furnished by <br /> the owner,tenant or any other party,the reasonable market value of such items must be added to the <br /> estimated cost or contract price for permit fee purposes. In the event that there is a dispute on the <br /> amount of the job cost,the City may request the submission of a signed copy of the actual contract. <br /> .._, . ,_. f �., _. <br /> 3i "S-y',4r y��'.� ....,:.. .,� ..:... <br /> sx�.�''�.2s�'_..� �'].k':".� . . � . .' a,. �' ' •: <br /> rd .. .... .. ... .».. _ .. . . 1_. . ._.. . <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 /> correct. <br /> Applicant's Signature: Date: ��—'�(��l� <br /> 3 <br />