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Jan 1,4 ZOin 1z: •tbr19 Mr LNbt1KJ1Z1 rrin P- 0 <br /> M::• <br /> R � <br /> r'1 S'•w.ti.:a •.t:•..wn•.2:.4 <br /> v'1._._I.•..__..._»..-a...aw....a_..�..-.• ..a..._.. _ .,•....._w ca..w....__v......a..�.....r a.�a:.i:.,..:..a....t..:......a...w. <br /> 1. Ube <br /> not geaquire modification to electrical or gas service. <br /> � s..o-a _.,. ..r wenn n.•'...w,_...-:_..e,..........►._.....�.ter mss._n.....�..w..r.r•./......_• ,..... <br /> :t. le imprnv�d:ncft.}lod n..wa.pl nna.d I.y t{Rn l,n.,,.anavw�r raw lino-.ss.cl nnnFrao}o�. <br /> ..Kip next SCcxm>n,it iris Ypiacy.; �..Ulk-t?i rrrfrin i 1 a.tw <br /> State Surcharge $ 5.00 <br /> Mail-In Fee Of Applicable) $�2,0 <br /> Total Permit Fee $ <br /> If above does not apply;follow guidelines below: <br /> 1. CQNTRACT PRICE *is 1.25%of contract price with a(Minimum Fee of 550.000)) <br /> J J <br /> x.0125 S (0;k ` 1 <br /> (contract price) (minimum 550.00) <br /> 2. ,STATE SURCHARGE R-511, x.0005 $ 41 � Z <br /> u (contract price) <br /> 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00 <br /> K'1' ...oa tMa nnA.el mt:w.ets.t Anli.ar e.nnunf niaorII/'A ♦nr iha <br /> In itm clixlnmer rtir then wixk(lune _iranv ninterfal.tuu_iu11=1I labor or installations are nwistied by <br /> vst:.....•.eaT .._..1,.•.. ._.._..1....dt.....r. r.. I.n....:! Frr. 1...-tti-.e•n..~WI., the t"t therr.� Ai�r.ute nn tho <br /> i MUUnt of Ales jut. UUM, Aeo City leeay-ieaiiaatt :1,o•bu6LRA*6e H1e of a i.16e-.W l i.a:ry of t11v b+:tu;.�gootraGt. <br /> TMS..r.d..rni6.a�A MOrrra'.s.r•.i'. .o e..r o . r.a�•ee..a..no '.T o c..-ti ua.ar..l e...rm.r ..yrr.-_ti.•a_.,.. wl l .. _ __. <br /> wont in Maul twwruaiiya wlttt titG LItutileaMQ3 Of ui0 ctty CUtU tt•v <br /> correct.�-• ---- -----•--- -.... ........ ...... .... ...... .-.- ....._._.. ..><. ...-.,.....�.•.. .w.... ....., <br /> Applicant's Signature: Date: <br /> / AK-40' <br />