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10/22/2014 14: 51 7635354379 GOLDEN VALLEY HTG PAGE 63/04 <br /> ;,,, � ' P��tMIT F��eA►L�ULATI4N(S) � <br /> '� BAS�D()���--2Ub2 S'�'A,TE'STA`x'UE <br /> � Yes,this sectio�n applies <br /> The replaeemenF of a R�sidential fixture or appliatice that mcets al1 thrce of tha following requirements: <br /> 1, es not rcquire modification to electrleal or gas strvice. <br /> 2, Has a total co�of$500.00 or less;excl � t}te cost of t}ie fixturc oK appliancc=and <br /> 3. IS improved,insta)led or repfflccd by the homeowner or licetased contractor. <br /> Skip next section,if this applies; Cost of Permit $ I5.00 <br /> 5tate SurchArge $ 5- � <br /> Ntail-InFee(If,Applicable) $ 2.00 <br /> 'Total�ermit Fee �� <br /> �ERNICT k'�'E CtkLCUi.A�T�ON(S)�J�$5 OV�n$S�a.UO _ ; <br /> If above does noc apply;follow guidelines below= <br /> 1. C NTRACT P�� '� is 1.2J%of contYact price with�(Minimum Fee of�50.00) <br /> x.0�25$ � <br /> (co ract pnce) (mioimum SSO.UO) <br /> 2. STATE SURC'�E � (r' /� <br /> x.0005 $ � v <br /> (c ntra t price) <br /> 3. P05TA,GE 8t HANDI,ING(Only on Mail-In Applications) $ 2,00 _ <br /> I pv <br /> 4. TO fAL PERI�'�a�'FEE(Add Lines 1-3 Above) � + ����! <br /> ■ ' CONTRACT PRIC� or JOS C05T means tho accual or asti�ttated dollar amount charged for the <br /> permitted work iacluding atateria�s,labor, profit,and other�xed costs. It as the amount co be charged <br /> to the customer for the work done_ If any material,equipst�e�at,labor oz'installations are furnished by <br /> the owtter,tenant or any other p&Cty, the reasonable market vt�lt�e of such iterns must be added to tlae <br /> estimated cost or conir&ct price for pertnit fee purposes. In the cve�t that there is a dispute on t}ae <br /> amount oF ihe job cost, the City may rcquest th�e submission of a signed copy of the aetual contract. <br /> Iwi�CHANIC�L�ERMIT�PPL�CATION A�"k�EMENT <br /> The unclersigned hereby applies to the City for issuance o�a Mechanical Permit, agrees to do all <br /> work in strict accordance �vith the ordi�ances of tlie C�ty and the regulations of the State of <br /> Minnesota, and certifies that all statements made on thas application are complete, true and <br /> correct. <br /> A�plicant's Signature:`�,� � Date: �� ��� <br /> 3 <br />