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From:COUNTRYSIDE HEATING & COOLING 763 479 2518 05/19/2014 08:30 #961 P.0031003 ❑ Yes,this section applies 7"he replacement of a Residentia]fixture or appiiance that mee s al1 three of the following requirements: 1. Does not require modification to electrical or gas service. 2. Has a total cost of$500.00 or less;excludin�the ost of the fixture or appliance:and 3. ]s improved,installed or replaced by the homeo ner or licensed contractor. Skip next section,if this applies; Cost of ermit $ l 5.00 State Su harge $ 5.00 Mail-In ee(If Applicable) $ 2.00 Total Pe mit Fee $ r , If above does not apply;follow guidelines belo�v: 1. CONTRACT PRICE * is 1.25%of coniract pri e with a(Minimum Fee of$50.00) r I 30o X.0�25$ ��1. �,r' (co�tract price) (minimum$50.00) 2. STATE SliRCHARGE �' x.0005 $ � 6 5 (contract price) 3. POSTAGE&HANDLING(Only on Mail-In Appli ations) $ 2.00 Q. T'OTAL PERMIT FEE(Add Lines 1-3 Above) $ ��fD . �� ■ * CONTRACT PRICE or JOB COST means the actual r estimated dollar amount charged for the permitted work including materials,labor,profii,and othe fixed costs. It is tbe amount to be charged to the customer for the work done. If any materia3,equip ent, labor or installations are fumished by the owner,tenant or any other party,the reasonable mark value of such items must be added to the estimated cost or contract price for permit fee purposes. ln the event that there is a dispute on the amount of the job cost,the City may request the submissi n of a signed copy of the actual contract. The undersigned hereby applies to the City for issuance o a Mechanical Permit, agrees to do all work in strict accordance with the ordinances of the Ci y and the regulations of the State of Minnesota, and certifies that all statements made on th's application are complete, true and correct. Applicant's Signature: Date: �/� ��/� 3