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Oct 26 2016 6: 35PM HP LASERJET FAX P. 3 <br /> 4 � <br /> • � s <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or&221iance that meets all three of the following requirements: <br /> L Does not require modification to electrical or gas service. <br /> 3. <br /> 14n_9 a*,,+-I cont of 5500.00 or loon:exoludinc the coat of the fixture or appliance:and <br /> ... •r....t:a.'�avu•u,.u�uu•w u. ,vts.-svru u�. ...c.w.,•R......c. �.. •,�w.s:,u.ti..........t... <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State SurchwSo <br /> Mail-In Fee(If Applicable) $ ,00 <br /> Total Permit Fee S <br /> �.WMISMa. . <br /> Wahpovc dr•c.rir t nnnly:tr,llow#uidUiata balow: , <br /> 1. l.t/I�iQHGT rAlGFi la L.2J%e�f wuua{.{p{roc whU a(Tr7luuupua 7"tia vl,Jd.00) <br /> �•�� ! r x.0l 25$ <br /> (cnntrut trim..) (minimum 550.00) <br /> 2. STATE SURCHARGE �j ~J <br /> X .0005 $ I <br /> (contract price) <br /> .S. YUa t Alit&HANDLING(only on man-in Appttcaidons) S 2.00 <br /> 4. TOTAL PERMIT FEE(Add Lines I-3 Above) S '� <br /> ■ CONTRACT PRICE or)OB COST means the actual or estimated dollar amount charged fore <br /> permitted work including materials,labor, profit,and other fixed costs. It is the amount to be charied <br /> to the customer for the work done. If any material, equipment, labor or installations are fureishedi by <br /> tho ow-nor,Conant or uny other party, the reanonabie market value of aueh items muct be added to Rhe <br /> estimated cost or eonLII price fum permitfee purposes.—fn the event that theme is a dispute on the <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 acrid <br /> correct. <br /> Applicant's Signature: Date: <br /> 3 <br /> i <br /> 1 <br /> 1 <br /> i <br />