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11/17/2015 16:49 7635354379 GOLDEN VALLEY HTG PAGE 03/04 <br /> , , <br /> ' PE�,Iv11"r,.�`Fs�Gt�,�TJLA'��QN(5) ;• � . <br /> �$ASEl7 0�"�''�-2D02,,�`t'ATE�T.�4'�'L?E ' <br /> ❑ Yes,thas section appl�es <br /> �'he rcptaceznent of a Resideptial fixture or� li�p ance that meets all three of the following requirements- <br /> 1_ oes not rcquire modi�icatio�z to eleccrical or gas service. <br /> 2. Has a totai cost of�SOOAO or less;excludin�the cost of the£ixtuxe or applia�ce:and <br /> 3. Is improvcd,installed or replaced by tk�e homeowner or licensed eo�tractor. <br /> Skip next sectxon,if this applies; Cost of Permit $ 15_00 <br /> State Su�c�,arge $ �.00 <br /> Mail-�n Fce(IfA�p]icabl�) $ Z.00 <br /> Total Perroit kee $ <br /> "' �'ERMT'X?���CPiI,�C�'X;ATIOh1 S --��►BS"O� , '$5�0.0!0 . <br /> If above does not a�ply;follow guidelines below: <br /> 1_ CONTRAC'f' Zt�CE * is 1.ZS%of contract price with a(Mininxum Fee ot�50.00) <br /> _ ��d�• � x .Q125� � U <br /> (cantract price) (minimu�550.00) <br /> 2. S'�ATE SU RGE r� � �j <br /> V y x.0005 � ( � �.J <br /> (contract pt7ice) <br /> 3. �OSTAGE&HANDLING(Oz�ly on Mai[-In A,pplications) $ .�.g� <br /> 4. �'OTAL P��IT FEE(Adcl I.ines I-3 Above) � C �� <br /> ■ � CQN�'�,ACT PRrCE or JOB COST tttearts the actual or estimated dollar amount charged for the <br /> pet-mitted work including materials,labor,profit, and other fixed costs. �t is the amount to bc charged <br /> to Ihe customer�'or chc work dope. zf ar�y material, equipment, labor or installations are fumisiied by <br /> the owner, tenant or any 4ther pa�ty, the reasonable rrtarket value o�such items must be added to the <br /> estimated cost or contract �rice for permit fee purposes. In the event that tl�ere is a dispute on thc <br /> amount of the job eost, the City may request the siibmission of a signcd co�y of the act�,al contract. <br /> ', ,',�" ME�k�ANZGAL PER�'� Q.�'�LICAT�ON AG��1I�IET�IT ' <br /> T�te undersigned�aereby a�pl�es to the Ciry :for issuance o�a Meehanical �ezxnit, agrees to do ala <br /> work in straet accordance with the ot•diz�az�ces of the Cxry a�nd the regulatao�s of the State of <br /> Minnesvta, and certifies that alE statexne�ts �nade on this application are complete, true and <br /> correct. <br /> � ' � 7 /S <br /> Applicant's Signatuze: �&t�; <br /> 3 <br />