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11-05—'14 18:32 FROM— 1-140 P0006/0007 F-255
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<br /> ❑ 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, Has a total cost of$500.00 or less;excluding the cost of the fixture or appliance:and
<br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of Permit $ 15.00
<br /> State Surcharge $ 5.00
<br /> Mail-In Pee(If Applicable) $ 2.00
<br /> Total Permit Fee $ 1
<br /> if s ? as �. C'1' ' W 1�r
<br /> :enx 4;Rit ►d' d ' � ar flMAT Tao O til. •r
<br /> If above does not apply;follow guidelines below:
<br /> 1. CONTRACT PRICE * is 1.25%of contract price with a(Minimum Fee of$50.000)p)(
<br /> ` �t19 x.0125$ tr f
<br /> (contract price) (minimum$50.00)
<br /> 2. STATE SURCHARGE
<br /> x.0005 $
<br /> (contrac price)
<br /> 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00
<br /> 1U4 2e
<br /> 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ `
<br /> • * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the
<br /> permitted work including materials,labor,profit,and other fixed costs. It is the amount to be charged
<br /> to the customer for the work done. If any material,equipment, labor or installations are furnished by
<br /> the owner,tenant or any other party,the reasonable market value of such items must be added to the
<br /> estimated cost or contract price for permit fee purposes. In the event that there is a dispute on the
<br /> amount of the job cost,the City may request the submission of a signed copy of the actual contract.
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<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 and
<br /> correct.
<br /> 10,
<br /> tf-9//4
<br /> Applicant's Signature: Date: /s/
<br /> 3
<br /> 1
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