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Uil11/ GU10 lo:�o /b3�311�n1 llt�NS TANK iNC PA�E 93 <br /> + �- <br /> � � . ��'�`�C�ILCYJLA']�t'7N(S) <br /> L�.e�EI�t?��'-2��TATE ST�ITUE , <br /> Q Yes,thia s�cxian appiies <br /> The replaccimens of a Acsidc�ntiat fixq�re or appliance that me�ets at1 three of the following requiromcnts: <br /> 1. DOCS 1fOt i't�vi1�modifiCatian tq eleGiTlCfll 8i gas SCNice. <br /> 2- klas a�of�500.00 or Ics�;� c 'n the oost ofthe fixture ox appliance:and <br /> 3. Is improved,instafied or replaced by the hrnneowncr or licensed corrtractor. <br /> Skip next section,it'this appli�s; Cost of Permit $ I 5.00 <br /> State Surch�ge $ 5.00 <br /> Maia-In Fce(If Appiicabie) $ 2.40 <br /> Total Pcrmit l�c� � <br /> ��v�z���c�,cui.A�r�ar�s -ro�s av���soo.a� <br /> If�bove does not s�pPfiy;follow guidelines below: <br /> t. CO�R� T�� •is 1.259�b ofcoMract price with a{Mi�imAm Fec otS5Qa1� <br /> ��,�so,ao X.o�zs a <br /> t��Pn�) (minlmnm S30.o0) <br /> z. sTA�sv�c�a�,c� <br /> -- �1,950.Q0 x.0U0S $ <br /> {conasct pnce} '" <br /> 3. POS'1'ACiE dt HANDLING tQnty pp�il-Iri Applicetions) $ 2.p0 <br /> 4. 'I'OTAL PERMTT F��(Add Lines 1-3 Abov+e) $ <br /> • * C4Ni'1Z.4.CT FRTCE or J0� �pgT megrts the actual or estimated dvilar amount ch�ed fnr�G <br /> permitted work including matcrials,tabp�r profit,and orher fixed vasts. It is the amouni to be chsrged <br /> ta she cusio,mer fnr t�e work dono. If atry material,ecluipmcm, labvr ar lnstatlacions arc furnishod by <br /> thc owner,tenra+t oir ariy other party,t�e reasottsbte m�rket valuc of su�h items m.ust be$dded to the <br /> e.stimared cost or contr�ct pxicc for pemnit fee purpns�s. 1n the event t3sat the� fs o dispute on ttie <br /> amourn of ths job cost,tt�Ciry r�ay request the Futmaission of s si�ncd copy of the actual co�nuaet. <br /> ',�Chf�42V'tC�.,P��il'�iiT AF�'S.ICATIC7N AG1�E� � <br /> 7"he eitidersigned her�eby applies ta tlte C�ty for i.tsuance of a Mechar►ica.l Permit,agrees to do af� <br /> work in strict aeeordaxtce with tlsc ordinancev of tb.e Cit,y and the regulations qf the St�te p� <br /> Minne.a�ta, areci ecreifies that al! StBtenrients made on this applic�ttion are complete, irue and <br /> correct. <br /> l�,pplicant's 3igmature: �i�iT�c..�./!,�¢�7�ia1� t?ate• , <br /> a�m�uj�_ <br /> 3 <br />