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■0 <br /><3 <br />5 . <br />G EQUIPMENT <br />Wood stove with flue <br />Wood combination or add-on <br />Factoiy fireplace with flue <br />Factoiy Fireplace (s)____ Freestanding ___ <br />Wood Stove (s) ____ Franklin, other <br />Masonry <br />Brand Name ModelNo. <br />Mfgr’s Min., Clearances, side rear , min. flue dia. <br />Total <br />No. <br />No. <br />No. <br />Kitchen Exhaust ducted recirculating cfim <br />Bath Exhaust (must be ducted outside) <br />Other Fans: Locations <br />cfin <br />cfin <br />3\Dcx V x \ -1 CC)OH\-p / l^yi^olal. <br />FUEL CjJlL* <br />II <br />RAGE (MUST BE APPROVED BY FIRE MARSHAL) <br />Bsollation ____ Removal <br />Ftieloil: ____ gallons ____ underground ___ <br />LPGas: ____ gallons <br />Other <br />inside outside <br />, _______________ ____ Gas opening <br />\ \ ^073^5 fA(i I t;oko \/wyt^(CX fit <br />PERMIT FCS CALCULA1 <br />1. 1.1^% of Contract Price* or Minimum Fee fS35.00) _ <br />X 1.25 $ <br />2. <br />3. <br />4. <br />(contract price) <br />State Surcharge. ** Add the State Building Code Divisi <br />/(c/QOO»^ X . <br />(contract price) <br />Pnstaye and Handling (Only maU-in applications) <br />TOTAL PERMIT FEE (Add lines 1-3 above) <br />Surcharge to each permit. <br />on <br />0005 9.fD <br />L <br />$ <br />* CONTRACT PRICE or JOB (X)ST means die actual or estimated dollar amount charged for the permitted <br />woric ineiiMting materials, labor, profit, and other fixed costs. It is the amount to be charged to die <br />customer for the work done. If any material, equipment, labor, or installation are furnished by the owner, <br />fynant or any other parly die reasonable maricet value of sudi items must be added to the estimated cost <br />or contract price for permit fee purposm. In the event that there is a diqiute on the amount of die job cost, <br />the City may request the submission of a signed copy of the actual contract. <br />♦* The STATE SURCHARGE is .0005 of the contract price under $1,000,000 or $.50 - whidiever is <br />greater. For valuations ovet $1,(X)0,000 call the Dqiartment of Inflectional Services for the price. <br />The undersigned hereby applies to the Ci^ for issuance of a Mechanical Permit, agre^ to do <br />all work in strict accordance with the ordinances of the City and the regulations of the Minnesota <br />State Building Code, and certifies that all statements made on this application are conqilete, true <br />and correct. <br />Applicant’s Signature <br />Approved By: <br />#-.5V^S Date; I I <br />Date: <br />. V <br />f f iWflini 11 * Ml I 11 • irti IS iTirn