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_ •� � <br /> . -:. _ . . . . _ <br /> WOOD BURNING EQUIPMENT _ - <br /> Wood stove with flue � <br /> _ Wood combi.nation or add-on _ <br /> Factory fireplace with flue � � � <br /> �� � Factory Fireplace (s) Freestanding � _ Masonry - <br /> Wood Stove (s) Franklin, other <br /> Erand Name ���` � i�,r�.e.�`� ✓ ;T�Model No. ,UI/�3�__ — <br /> Mfgr's Min.., Clearances, side ��, rear � z. , min. flue dia. S'� <br /> Total /o��" <br /> VENTILATION <br /> �No. Kitchen Exhaust ducted recirculati.ng �� <br /> No. Bath Exhaust (must be ducted outside) �� c� <br /> No. Other Fans: Locations � <br /> Total <br /> FUEL STORAGE (MUST BE APPROVED BY FIRE MARSHAI-) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> I,p Gas; gallons <br /> Other Gas opening <br /> . pERMIT FEE CALCULATION <br /> 1. 1.25% of Contract Price* or Minimum Fee ($35.00) �� <br /> /��� �J x .0125 $ .5-S' <br /> (contract price) <br /> 2a State SurcharQe. ** Add the State Building Code DiXisio�5 $ �J <br /> Surcharge to each permit. <br /> (contract price) <br /> � or $.50, whichever is greater � �_ <br /> 3. Posta�e and Handlin� (Only mail-in applications) ` <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) � ����� <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permitted <br /> work including materials, labor, profit, and other fized costs. It is the amount to be charged to the <br /> customer for the work done. If any macerial, equipment, labor,or installation are furnished bY the owner, <br /> tenant or any other party the reasonable market value of such items must be added to the estimated cost <br /> or contract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost, <br /> the City may request the submission of a signed copY of the actuai conuact- <br /> ** The STATE SURCHARGE is .0005 of the contract price under $1,000,000 or 5.50 - whichever is <br /> greatez. For valuations over$1,000,000 ca11 the DePa�ent of Inspectional Services for the price. <br /> The undersigned hereby applies to the City for issuance of a Mectianical Permit, agrees to do <br /> all work in strict accordance with the ordinan��s II�de on this applir.�ation are omple�es� <br /> State Build.ing Code, and certifies that all <br /> � and correct -_ __ ` : <br /> _ -- � _ r, ' Date: l `" —� <br /> _ Applicant's Signature: <br /> _ Date: <br /> APProved By:_.. �._ . - <br />