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L11 r ur UKVNU 1-IrrLILAI1VIN rUK M LtLA.1.N1UAL YtKM11 Page 2 a3 <br /> COOLr1G SYSTEMS <br /> Quantity: <br /> Make: <br /> Model: <br /> Tons: <br /> H.Power <br /> FIREPLACES <br /> Gas factoryfireplace <br /> des urning factory fireplace with flue <br /> Wood Stove` <br /> Wood stove with flue'-- <br /> Brand Name Model No. <br /> VENTILATION <br /> NNQ. Kitchen Exhaust duct recalculating cfm <br /> No. '— --Bath..Exhaust(mu ave duct outside) cfm <br /> No. Other Fans: Locations cfin <br /> L STORAGE(MUST BE APPROVED BY FIRE MARSHAL) <br /> In tion or Removal <br /> Fuel oil gallons underground inside outside <br /> LP Gas: gallons <br /> Other Gas opening <br /> PERMIT FEE CALCULATION(S) <br /> 2002 State Statute Yes This Section Applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> 1) Does not require modification to electrical or gas service. <br /> 2) Bas a total cost of$500.00 or less;excluding the cost of the fixture or appliance: <br /> and <br /> 3) Is improved, installed or replaced by the homeowner or licensed contractor. <br /> Skip next section; Cost of Permit $ 15.00 <br /> State Surcharge$ .50 <br /> Mail-In Fee $ 1.50 <br /> If above does not apply, follow guidelines below: <br /> 1. Contract Price* is .0125%of job with a Minimum Fee of($35.00) 5iii <br /> __ g07 x.0125 $ `� <br /> (contract price) (minimum$35.00) <br /> 2. State S_u_rcharge. ** Add the State Building Code Division a Minimum Fee of($.50) <br /> x.0005 $ <br />