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Dec 17 2015 11 : 38RM HP LRSERJET FAX p. 3 <br /> SD R.� /4 £ . at F T' S. C. . <br /> � 34.� �-�' 1�• t .}s����� �'� � � �;�.�( e,�"�4e�. �C <br /> c ,r-f1:- � .u:.`� `��n�-�ra,,j�,.�;��,�4I� � � 1����'�{��d�Sy,� � ��'a ��+". <br /> - ��'�.� a,��"dhti wv�?r�1.r;i�'vt,l C»."�j,,,.*.�.-,.:, —,.e;i:� <br /> ❑ Yes, this seciion applies <br /> The repEacement of a Residential fi�cture or ap�jiance that meets all three of the following requirerrients: <br /> 1. Dces not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or a{spliance:and <br /> 3. Is improved, installed or reptaced by the homeowner or licensed contractor. <br /> Skip neact section,if this applies; Cost of Permit $ 15.00 <br /> State Suroharge $ S.OQ <br /> Mail-in Fee(IfApplicable) $ 2.oa <br /> Total Permit Fee $ <br /> �.z�:nii;. ^��iii�[� .;:--.; <br /> if above does not apply;follow guideliees below: <br /> i. CON'�''RACT PRICE "is 1.25%of contract price with a(Mini�num Fee of S50.U0) <br /> �` ��� x.0125$ �C�� C� <br /> (contract pnce) (minimam 550,00) <br /> 2. STATE SIJRCHARGE <br /> � 1« x ,0005 $ t�� <br /> (contract price) � <br /> 3. POSTAGE&HA]VDi.[NG(Only on Mail-In Applications) $ 2.40 <br /> 4, TOTAL PERMIT FEE(Add Lines 1-3 Above) S ��� <br /> ■ # CONTRACT PFiICB or 30B COST means the acival or estimated dollar amount charged for Che <br /> permitted work induding rnaterials, labor,profit,and other fixed costs. It is the amount to be charged <br /> to the cuswmer for the work done. [f any material, equipment, labor or installations are furnished by <br /> the owner,tenant or any other party,the reasonabte market value of such items rnust be added to t�e <br /> estimated cost or contract price for permit fee purposes. ln ihe event that therc is a dispute on d�e <br /> amount of the j�b cost, che City may request the submission of a signed copy of the aciva] contract. <br /> �. l.r.r FI�h V n4 4`•, `� �:rLi; <br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do ail <br /> work in strict accordance with the ordinances of the City and the regulations of the State of <br /> Minnesota., and cercifies that all ents made on this application are complete, true and <br /> correct. <br /> Applicant's Signature: � Date: ��"���� <br /> - v+r, <br /> —�.c'': ° "`f }, '' -�.6 <br /> .``'�`��a .. . �t� � <br /> � 1 :�i <br /> 3 � �;--� �r�N' <br /> �� � ��� . <br /> ,; <br /> 'r+.} _ � t��'.� .1.�' �7''�� �4�f�''� �'`p,�' <br /> ,;,, ��j'2s <br /> '�a'"5L-�. <br />