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� � ' <br /> �pQ g r E�UIPMEN�' <br /> ' Woctid stove with flue <br /> � Wood cambination or add-on <br /> Factory fiz�eplac� with flue <br /> Factory Fire�lace (s) _ _ Freestanding Iv�asonry <br /> Woad Stove (s) Franklin, other <br /> Brand Name Model No. <br /> Mfgr's Min,, Clearanccs, side , rear , mjn• T�e�a. <br /> VFN'�'IL TiOt�I <br /> No. Kitchen Exl�aust ducted recircuiating cfm <br /> Na. � Bati� F.xhaust (must he duc[ed outside) �rm �fm <br /> Nq, Other Fans: X.acations <br /> —�— Tatal � <br /> FiTEL S ORA E (MUST B� AFPROVED �3Y FIRE MARSNAL) <br /> Installativn Removai <br /> � ruel oil: gallons undergraund M inside � autside <br /> � LP Gas: �allons <br /> � Other � Gas o�enil�g <br /> PE IT FE AL UL TI() <br /> �, 1.25%a of Cont�'act rice* or Minim m Fee ($3 .0� �� ' ^ <br /> y� :t'� x .0125 � <br /> (cantract price) <br /> 2. State Surch�� ** Add the State Building Codc Division <br /> Surcharge to each permit. / �'� X •�5 $ •� <br /> (cuutract pncc) <br /> or $.SU, whichevex is �reater 1.5 <br /> 3, pos��e and I� ndli� (Only mail-in appiications) $ <br /> �, TOTAL ��RMIT FEE (Add lines i-3 above) <br /> $ ` � � <br /> * CONTRACT PRICE or J�B CpS'�'means the actual aX estimatcd�o11ar amounc charged for the permitted <br /> work including materia4s, labor, �rofit, 3nd ather fued costs. It is t�e amount ta be �l�arged to ttie <br /> customer for che work done. Zf any material, equigusent,labor,or installation are fu3rnished by t�e ownex, <br /> tenant or any othet partY t3�e reasonable �ket value of such items must be 2ddecl to the estimated cost <br /> or contract price for permit fee purposes. In the event that there is a disgute on Lhe smount of th�job cost, <br /> the City may request the submission of a signed capy of the actual cont�8et. <br /> +* The 51'AT� SURC(-IA�GE is .0()OS of the contract price under $1,000,000 or $.SO - whichever is <br /> greater. Far valuations over $1,OOd,00Q call t�e Aepartment of IC�Spectional Services fdr the price. <br /> 'The undersigned hereby applies to the Ciry for issuance of a �echanical Permic, agrees to do <br /> all work in 5trict accordance with the ordinances of the City and tiie regulatio�►s of the Minnesota <br /> StA�e Building Cade, and ceztifies that all statemez�ts made on this application are com{�iete, tnie <br /> and correGt. • <br /> .. �' � <br /> Apgiicant's Signature: <br /> Date: L�' �" -S <br /> � Date: � '�"�/d� <br /> Approved8y: �� <br />