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06-03—'15 15:18 FROM— 1-877 P0003/0004 F-065
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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 mal cost of$500.00 or less; -xcluding 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 Fee(If Applicable) $ 2.00
<br /> Total Permit Fee $
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<br /> If above does not apply;follow guidelines below:
<br /> 1. CONTRACT PRICE *is 1,25%of contract price with a(Minimum Fee of$50,00)
<br /> $4793.25 C �� 2 "''''.V,__ d__s. : Z; t'A'Ic; 13:%.
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<br /> 2. STATE SURCHARGE
<br /> $4793.25 x(0,6,5':$; 2. 40
<br /> 3. POSTAGE&HANDLING(Only on Mail-In Applications) CS.' :2:00.:f',..,
<br /> 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) 461r„tiO4; r, ° t
<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 /> Applicant's Signature: LiL.
<br /> v .(/'V � iat0'; 6/3/15
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