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01/19/2016 11:10 7635354379 GOLDEN VALLEY HTG PAGE 03/04 <br /> ��� �� ,� <br /> �MIT.��� C�LC��,TIO�(�� , <br /> � BASED 0�'��' .:20q2 STATE.��'A� ;,, �, ' ;, <br /> ❑ Xes,this sectzom applies <br /> The replaccment of a Rcside tial fixtu e or a ]iance that meets all three of the�'ollowing requirements: <br /> 1. Does not�equire rtaodif cation to electrieal or gas service. <br /> 2. Has a total cost of$500.00 ar less;exeludina the cost of the fixture ox appliance:and <br /> 3. Is imprpvcd,installed or repEaeed by the hpmeowner or licensed contractor. <br /> Skip next seetion, if th[s applies; Cost o�'Pertr�it $ 15.q0 <br /> State Surcba�ge $ L.00 <br /> l�az�-1n�'ee(If Applicable) � 2.00 <br /> Total�erimit Fee � <br /> �'ERMIT'�E� CAL��:7;j.;ATI0�1 ,�)-:,JQ�S OV�R 50';�:00 <br /> ZFabove does not apply;fo�low gui�ielin,es below: <br /> 1. CONT�tA,CT PRICE * is 1.25%of coritract p��ice with a(Minimum Fee of�50.00) <br /> Ix.0125 $ , �� <br /> (con ct price) (minimum$50.00) <br /> 2. STATE SURCHARGE �� �� �-l <br /> x.0005 � U <br /> (contra i pricc) <br /> 3_ POSTAGE&HANDLI�IG(Only on ivxail-In Appl�cations) � �2. , <br /> � a—D <br /> 4. '�QTAL YERMIT FE�(A,dd Lines 1-3 A,bove) g j � <br /> ` * CON�'�ACT PRICE or JOB COS'�' means the actual or estirnated dollar amount chargcd �or the <br /> permitted wo�k inciuding materials, labor,�rofie,and otl�ex fixed costs. it is the amouac ro be char�ed <br /> to the custotl�e;r for the work done. If any material, equipment, laboz•or installations arc fi�rnished by <br /> the ow�nez�, tenant or az�y othcr party,the roasonabte market value of such items must be added to The <br /> estin�ated eost or contract pz�ce fox' �ermit fee �urposes_ Z�� the evcnt that therc is a dis�ute on tk�e <br /> at�ount of the job �ost, the City may requesf the suba�,ission of a signed copy of the acCuA] contract. <br /> ;. 1VI;EG�Z��;:�E1�MIT��LTQATZ��1 A�RE��:�,�`�TT <br /> _ �� <br /> The u�dersigned h�,reby a�plies to the C�ty for issuaz�ce of a Mechanxea� �ermit, agxees to do al� <br /> work i� strict acco:rdance witk� t�te ordiqa�ees of the City and the regulations of tk�e State of <br /> l�i�.z�esota, and ce�tifies that all statemez�ts made on this application are complete, tnie and <br /> correct. <br /> ) ` 1 <br /> Appl�cant's Signatuxe� bate: <br /> 3 <br />