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10/201,2011 08: 27 6127218691 SODERLIN PAGE 04/05 <br /> P.ERIvIIT FEE CA.LCULA.TiON(S) <br /> B�SBn OFr - z002 STATE STATUr <br /> ❑ Ycs,this sccti�n��Pplies <br /> Thc replacemei�c of a Rcsidcntial .1ixl.ute or ar,Rli;.tnce that mects 1l] lhrcc of lhe foll��wing requircmcnts; <br /> 1. Docs not rcquirc modific�tipn to elecu•ical or Sas servicc. <br /> 2. 1-las a total cost of$500.00 or Icss;cxcluilinf,t.he cosi.oP�'he Pixture or a��pliance; and <br /> 3, Is improv�d,insl.alled pr replaced hy thc homcowner or liccnsed con.lracl•vr. <br /> Slci��ncxc section, if Uiis�pplics; CUsI of PermiC $ 15.00 <br /> State SurcliarGe S 5.00 <br /> Mail-h�i'ec(Tf Applicab[c) S 2.UU <br /> Total Pcrmit Fee $ <br /> PERiv�IT F�L CALCLTLATiON S -JQBS OVE:R$500.00 <br /> if abovc docs not apply;follow gui.cicli.nc�bclow: <br /> l, COIYTRACT PRICT *is 1..25"/n o!'conlract pr.icc with a(Minimum Fee of�50.00) <br /> TJ l���� a.0 I 25 $ ���� ��✓'� <br /> (�pmr��cl pri���) [minima�n$50_00) <br /> 2. Sl'A'1'I:S[112CI•IAR(;1�. ,U�� <br /> x .OQpS $ �, <br /> (conu��ct.�irice) - <br /> 3, POSTAGE c�HANDLLNG(Oiily on Mail•in An��licati�n�) $ 2.00 <br /> 4. '1'OT.AI., P.i;RMi�'FTE(Add Lincs 1-3 /lhave) $ <br /> • "' (.:UNTRACT PRIC� or JO$ CnST rnean, thc �ctual or estimated dollo.r nmoun� ch,�r�ul for tl�c <br /> perniittcd work including m�t�ria.l`, ]��Uor,profit,and other fixed eusCs, It is the a�nount to he chsir�;er.l <br /> ro the customcr Cor fhc work done. l f a.i�y mt�.lCr.ial, cquiprnent, lal.�or or inst�llations arc furnished hy <br /> I.lic owncr, [cnlnt or�ny OthCr p��ty, tl�e reasona.hle m�.rltel valuc of such items must tio �iddcd to thc <br /> cstimal.eil cUsf or contract price fpr pern�if Fcc ptnposcs. In t.hc evcnt tl�at there is a di.apulc un thc <br /> an�ount of chc jnb cost, fhc t:ity may requesc fho submission of a si�ned c;vpy oF the acl:ual cnntracL <br /> MECHANTCAL PERMTT APPi ICA7'.CON AGREEMENT <br /> Thc u.ndcrSiSncd hcrel�y appJics to thc City Cor istivancc of 1 Mc:ch;.tnic�[ Pcnnil, �.grecs co do all <br /> work in stricl accorda.ncc witlt �h� ardinanees uf thc City 3nc{ the rC�LIIAlians pf tI1C St3te of <br /> Minncsota, and ccr�iiie� tl�at all sta.tcments madc on this aPplication ��re complcic, truc �nd <br /> corr�cc. <br /> A� licant's Si naturc: D �Q �Q — <br /> 1 P � Datc: /� <br /> Reset Form <br /> 3 <br />