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From:COUNTRYSIDE HEATING & COOLING 763 479 2518 08/21/2012 11 :27 #582 P.003/003 • .kgs.d.w-a. "-a. o A - ,4 h:�.a?>,{,Crrns1'd:'t': °.1 �'�- ".:r,. 14.}'7.yr:;.,n-:}n•.r%:,:�T..-;:.... I.ar>..... '�T:f�Skm. "t - S t� •.i1 ;'M1 - .;xx;.v " �''1" 3�^`'t;., . •rte ,s.. �„�°�'Ji�� `�`G�r�pl�b,?.�;7ixeit -v=' �" • `6 �r�.ry g.,::,., tii k > ! ht't i e 'y}..1;. Q C (`LTi (vv„ r i 2 i r :,5"' +�n =*- K'zy' ,:a...::,.. ) L1.�C,.�.t .?t�A-II�A1r� TKJr.;� ��M�4�. T' ._ ::� `� .. � h Yr '1 �R ❑ Yes,this section applies The replacement of a)tesidential fixture or appliance that meets all three of the following requirements: 1. Does not require modification to electrical or gas service. 2. Has a total cost of$500.00 or less;excluding the cost of the fixture or appliance: and 3. Is improved,installed or replaced by the homeowner or licensed contractor. Skip next section,if this applies; Cost of Permit $ 15.00 State Surcharge $ 5.00 Mail-In Fee(If Applicable) $ 2.00 Total Permit Fee .:•z,;:;k:°.>; 4 l Y3\'1.4• »' S i .a ... r. r �ars` !,:�- :-` If above does not apply;follow guidelines below: 1. CONTRACT PRICE *is 1.25%of contract price with a(Minimum Fee of$50.00) 4,000.00x.0125$ 50.00 (contract price) (minimum$50.00) 2. STATE SURCHARGE 4000.00 2.00 x.0005 $ (contract price) 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $52'00 • * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permitted work including materials,labor,profit, and other fixed costs. It is the amount to be charged to the customer for the work done. If any material, equipment, labor or installations are furnished by the owner, tenant or any other party, the reasonable market value of such items must be added to the estimated cost or contract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost, the City may request the submission of a signed copy of the actual contract. x „ , i ,r.. ;: gig.C.I COAL P1 RM1t Art . AT3OS "t IZ ; The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do all work in strict accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements made on this application are complete, true and correct. _ Applicant's Signature: --(� Date: 08/21/12 -763 6179- IG00 3